RFP T2471 Arbitration and Mediation Services 020217.docx

Bid Solicitation/Request for Proposal

Claims Arbitration, DOBI

Vendor’s {Bidder’s} Electronic Question Due Date (Refer to Bid Solicitation {RFP} Section 1.3.1 for more information.)

Mandatory/Optional Pre-Quote {Proposal} Submission Conference (Refer to Bid Solicitation {RFP} Section 1.3.6 for more information.)

NOT APPLICABLE

Mandatory/Optional Site Visit (Refer to Bid Solicitation {RFP} Section 1.3.5 for more information.)

NOT APPLICABLE

Quote {Proposal} Submission Date (Refer to Bid Solicitation {RFP} Section 1.3.2 for more information.)

Dates are subject to change. All times contained in the Bid Solicitation {RFP} refer to Eastern Time. All changes will be reflected in Bid Amendments {Addenda} to the Bid Solicitation {RFP} posted on the Division of Purchase and Property website and on www.njstart.gov.

Small Business Set-Aside Status |_| Not Applicable

|_| Entire Blanket P.O. {Contract}

|_| Partial Blanket P.O. {Contract}

|X| Subcontracting Only Category

|X| I |_| IV

|X| II |_| V

|X| III |_| VI

Bid Solicitation {RFP} Issued By Using Agency

Trenton, New Jersey 086250230 Date: February 2, 2017

Table of Contents

INFORMATION FOR VENDORS {BIDDERS}

NOTICE: This Bid Solicitation {Request for Proposal (RFP)} is part of the NJSTART Procurement Program. The Vendor {Bidder} is advised to thoroughly read all sections, as many have been revised, and follow all instructions contained in this Bid Solicitation {RFP}, including the instructions on the Bid Solicitation’s {RFP’s} Offer and Acceptance Page {Signatory Page} and read through all Quick Reference Guides (QRGs) located on the NJSTART Vendor Support Page (http://www.state.nj.us/treasury/purchase/njstart/vendor.shtml), in preparing and submitting its Quote {Proposal}.

Terminology is listed by new NJSTART term; {existing term} appears in braces.

PURPOSE AND INTENT

This Bid Solicitation {RFP} is issued by the Procurement Bureau, Division of Purchase and Property (Division), Department of the Treasury on behalf of the Department of Banking and Insurance (DOBI). The purpose of this Bid Solicitation {RFP} is to solicit Quotes {Proposals} for arbitration services as required by the Health Claims Authorization, Processing and Payment Act (the “Act”) (P.L. 2005, c. 352).

The intent of this Bid Solicitation {RFP} is to award a Master Blanket Purchase Order (Blanket P.O.) {Contract} to that responsible Vendor {Bidder} whose Quote {Proposal}, conforming to this Bid Solicitation {RFP} is most advantageous to the State, price and other factors considered. The State may award any and all price lines. The State, however, reserves the right to separately procure individual requirements that are the subject of the Blanket P.O. {Contract} during the Blanket P.O. {Contract} term, when deemed by the Director of the Division of Purchase and Property (Director) to be in the State’s best interest.

The State of NJ Standard Terms and Conditions (SSTC) accompanying this Bid Solicitation {RFP} will apply to all Blanket P.O.s {Contracts} made with the State of New Jersey. These terms are in addition to the terms and conditions set forth in this Bid Solicitation {RFP} and should be read in conjunction with them unless the Bid Solicitation {RFP} specifically indicates otherwise.

BACKGROUND

This is a reprocurement of the services provided under Arbitration and Mediation Services: Claims Arbitration, DOBI term Blanket P.O. {Contract}, presently due to expire on March 14, 2017. Vendors {Bidders} interested in the current Blanket P.O. {Contract} specifications and pricing information may review the current Blanket P.O. {Contract} T2471 at http://www.state.nj.us/treasury/purchase/pricelists.shtml and are cautioned that this new Bid Solicitation {RFP} addresses current requirements.

The Health Claims Authorization, Processing and Payment Act, enacted January 12, 2006, and effective on July 11, 2006, established a statutory framework for binding arbitration of payment disputes between payers and providers. The Act requires DOBI to contract with a nationally recognized, independent arbitrator to conduct arbitration proceedings.

Key Events

ELECTRONIC QUESTION AND ANSWER PERIOD

The Division will electronically accept questions and inquiries from all potential Vendors {Bidders} via the “Q&A” Tab of the Bid Solicitation {RFP} in NJSTART.

a. Questions should be directly tied to the Bid Solicitation {RFP} and asked in consecutive order, from beginning to end, following the organization of the Bid Solicitation {RFP}; and

b. Each question should begin by referencing the Bid Solicitation {RFP} page number and section number to which it relates.

Vendors {Bidders} may refer to the QRG “Submit a Quote” for additional instruction. QRGs are located on the NJSTART Vendor Support Page.

A Vendor {Bidder} must not contact the Using Agency and/or the Procurement Specialist directly, in person, by telephone or by e-mail, concerning this Bid Solicitation {RFP}.

The cut-off date for electronic questions and inquiries relating to this Bid Solicitation {RFP} is indicated on the Bid Solicitation {RFP} cover sheet. In the event that questions are posed by Vendors {Bidders}, answers to such questions will be issued by Bid Amendment {Addendum}. Any Bid Amendment {Addendum} to this Bid Solicitation {RFP} will become part of this Bid Solicitation {RFP} and part of any Blanket P.O. {Contract} awarded as a result of this Bid Solicitation {RFP}. Bid Amendments {Addenda} to this Bid Solicitation {RFP}, if any, will be posted as a File Attachment on the “Summary” page of the Bid Solicitation {RFP} in NJSTART after the cut-off date. (See Bid Solicitation {RFP} Section 1.4.1 for further information.)

EXCEPTIONS TO THE STATE OF NJ STANDARD TERMS AND CONDITIONS (SSTC)

Questions regarding the SSTC and exceptions to mandatory requirements must be posed during this Electronic Question and Answer period and shall contain the Vendor’s {Bidder’s} suggested changes and the reason(s) for the suggested changes.

SUBMISSION OF QUOTES {PROPOSALS}

In order to be considered for award, the Quote {Proposal} must be received by the Procurement Bureau of the Division at the appropriate location by the required time. Vendors {Bidders} shall submit a Quote {Proposal} either electronically through NJSTART or via hard copy.

Hard copy Quote {Proposal} must be submitted to the physical location noted below:

PROPOSAL RECEIVING ROOM – 9TH FLOOR

DIVISION OF PURCHASE AND PROPERTY

DEPARTMENT OF THE TREASURY

33 WEST STATE STREET, P.O. BOX 230

TRENTON, NJ 08625-0230

Directions to the Division are available on the web at http://www.state.nj.us/treasury/purchase/directions.shtml.

QUOTES {PROPOSALS} NOT RECEIVED PRIOR TO THE QUOTE {PROPOSAL} OPENING DEADLINE SHALL BE REJECTED. THE DATE AND TIME OF THE QUOTE {PROPOSAL} OPENING ARE INDICATED ON THE BID SOLICITATION {RFP} COVER SHEET AND IN THE “SUMMARY” PAGE OF THE BID SOLICITATION {RFP} IN NJSTART.

Note: A Vendor {Bidder} using U.S. Postal Service regular or express mail services should allow additional time since the U.S. Postal Service does not deliver directly to the Proposal Receiving Room. A Vendor {Bidder} should make every effort to submit its Quote {Proposal} well ahead of the Quote {Proposal} submission deadline to mitigate unforeseen delays or issues. The Vendor {Bidder} is solely responsible for the timely submission of its Quote {Proposal} in response to this Bid Solicitation {RFP}.

Procedural inquiries concerning this Bid Solicitation {RFP} may be directed to njstart@treas.nj.gov and/or (609) 341-3500.

The State will not respond to substantive questions related to the Bid Solicitation {RFP} or any other Blanket P.O. {Contract} via this e-mail address. For inquires related to substantive questions refer to Section 1.3.1 (Electronic Question and Answer Period).

NJSTART

The Division is pleased to announce its new eProcurement solution “ .”

Vendor {Bidder} Support:

Vendors {Bidders} are strongly encouraged to visit the NJSTART Vendor Support Page, which contains Quick Reference Guides (QRGs), supporting videos, a glossary of NJSTART terms, and helpdesk contact information.

The Vendor {Bidder} should utilize the QRGs before attempting to submit its Quote {Proposal} using the NJSTART process. It is the Vendor’s {Bidder’s} responsibility to ensure that the NJSTART Quote {Proposal} and attachments have been properly submitted.

ELECTRONIC SIGNATURES

Vendors {Bidders} submitting Quotes {Proposals} through NJSTART may sign the forms listed in Section 4.4.1 (Forms, Registrations and Certifications Required with Quote {Proposal}) and Section 4.4.2 (Forms, Registrations and Certifications Required Before Blanket P.O. {Contract} Award and That Should Be Submitted with the Quote {Proposal}) of this Bid Solicitation {RFP} electronically by typing the name of the authorized signatory in the “Signature” block as an alternative to downloading, physically signing the form, scanning the form, and uploading the form to NJSTART.

Vendors {Bidders} submitting Quotes {Proposals} in hard copy format, must provide forms with original, physical signatures, otherwise its Quote {Proposal} may be deemed non-responsive.

MANDATORY/OPTIONAL SITE VISIT

Not applicable to this procurement.

MANDATORY/OPTIONAL PRE-QUOTE {PROPOSAL} CONFERENCE

Not applicable to this procurement.

PRE-QUOTE {PROPOSAL} DOCUMENT REVIEW

Not applicable to this procurement.

ADDITIONAL Information

BID AMENDMENTS {ADDENDA}: Revisions to this BID SOLICITATION {RFP}

In the event that it becomes necessary to clarify or revise this Bid Solicitation {RFP}, such clarification or revision will be by Bid Amendment {Addendum}. Any Bid Amendment {Addendum} to this Bid Solicitation {RFP} will become part of this Bid Solicitation {RFP} and part of any Blanket P.O. {Contract} awarded as a result of this Bid Solicitation {RFP}.

There are no designated dates for release of Bid Amendments {Addenda}. Those Vendors {Bidders} who are on the bidholder list either through commodity code registration in NJSTART or by acknowledging the bid in NJSTART should receive notification of any Bid Amendment(s) {Addenda}. If a Vendor {Bidder} is not on the bidholder list to receive notifications related to a Bid Solicitation {RFP}, Bid Amendments {Addenda} are still viewable on the “Summary” page of the Bid Solicitation {RFP} in NJSTART.

BID AMENDMENTS {ADDENDA} WILL BE ISSUED AS FILE ATTACHMENTS, AND ARE VIEWABLE ON THE “SUMMARY” PAGE OF THE BID SOLICITATION {RFP} IN NJSTART. Vendors {Bidders} may refer to the QRG “Submit a Quote” for additional instruction. QRGs are located on the NJSTART Vendor Support Page.

It is the sole responsibility of the Vendor {Bidder} to be knowledgeable of all Bid Amendments {Addenda} related to this procurement. An interested Vendor {Bidder} should check the NJSTART “Open Bids” Tab on a daily basis to ensure review of the most updated information.

VENDOR {BIDDER} Responsibility

The Vendor {Bidder} assumes sole responsibility for the complete effort required in submitting a Quote {Proposal} in response to this Bid Solicitation {RFP}. No special consideration will be given after Quotes {Proposals} are opened because of a Vendor’s {Bidder’s} failure to be knowledgeable as to all of the requirements of this Bid Solicitation {RFP}.

COST Liability

The State assumes no responsibility and bears no liability for costs incurred by a Vendor {Bidder} in the preparation and submittal of a Quote {Proposal} in response to this Bid Solicitation {RFP}.

CONTENTS of QUOTE {Proposal}

Quotes {Proposals} can be released to the public pursuant to N.J.A.C. 17:12-1.2(b) and (c), or under the New Jersey Open Public Records Act (OPRA), N.J.S.A. 47:1A-1 et seq., or the common law right to know.

After the opening of sealed Quotes {Proposals}, including Quotes {Proposals} submitted through the NJSTART electronic process, all information submitted by a Vendor {Bidder} in response to a Bid Solicitation {RFP} is considered public information notwithstanding any disclaimers to the contrary submitted by a Vendor {Bidder}. Proprietary and confidential information may be exempted from public disclosure by OPRA and/or the common law. When the Bid Solicitation {RFP} contains a negotiation component, the Quote {Proposal} will not be subject to public disclosure until intent to award a Blanket P.O. {Contract} is announced.

As part of its Quote {Proposal}, a Vendor {Bidder} may designate any data or materials it asserts are exempt from public disclosure under OPRA and/or the common law, explaining the basis for such assertion. The location in the Quote {Proposal} of any such designation should be clearly stated in a cover letter. The State reserves the right to make the determination as to what is proprietary or confidential, and will advise the Vendor {Bidder} accordingly. Any proprietary and/or confidential information in a Quote {Proposal} will be redacted by the State. The State will not honor any attempt by a Vendor {Bidder} to designate its entire Quote {Proposal} and/or prices as proprietary, confidential and/or to claim copyright protection for its entire Quote {Proposal}. Copyright law does not prohibit access to a record which is otherwise available under OPRA. In the event of any challenge to the Vendor’s {Bidder’s} assertion of confidentiality with which the State does not concur, the Vendor {Bidder} shall be solely responsible for defending its designation, but in doing so, all costs and expenses associated therewith shall be the responsibility of the Vendor {Bidder}. The State assumes no such responsibility or liability.

By signing the Bid Solicitation {RFP} Offer and Acceptance Page {Signatory Page}, the Vendor {Bidder} waives any claims of copyright protection set forth within the manufacturer's price list and/or catalogs. The price lists and/or catalogs must be accessible to State Using Agencies and Cooperative Purchasing Program participants and thus have to be made public to allow all eligible purchasing entities access to the pricing information.

ANNOUNCEMENT OF QUOTE {PROPOSAL} INFORMATION

On the date and time Quotes {Proposals} are due under the Bid Solicitation {RFP}, all information concerning the Quotes {Proposals} submitted may be publicly announced and shall be available for inspection and copying except as noted below:

a. Information appropriately designated as proprietary and/or confidential shall not be available for inspection and copying; and

b. Where negotiation is contemplated, only the names and addresses of the Vendors {Bidders} submitting Quotes {Proposals} will be announced, and the contents of the Quotes {Proposals} shall not be available for inspection and copying until the Notice of Intent to Award is issued by the Director.

PRICE Alteration In Hard copy QUOTES {Proposals}

Hard copy Quote {Proposal} prices must be typed or written in ink. Any price change (including "white-outs") must be initialed. Failure to initial price changes shall preclude a Blanket P.O. {Contract} award from being made to the Vendor {Bidder}.

QUOTE {Proposal} ERRORS

In accordance with N.J.A.C. 17:12-2.11, “Proposal errors,” a Vendor {Bidder} may withdraw its Quote {Proposal} as described below.

QUOTE {PROPOSAL} WITHDRAWAL PRIOR TO QUOTE {PROPOSAL} OPENING

NJSTART: A Vendor {Bidder} may withdraw its Quote {Proposal} submission in NJSTART prior to the Quote {Proposal} opening; however, Vendors {Bidders} should note that while withdrawn NJSTART Quotes {Proposals} remain viewable by the Vendor {Bidder} on its Vendor Profile Homepage, they are removed from the Division’s view and cannot be considered for Blanket P.O. {Contract} award. The Vendor {Bidder} may submit a revised Quote {Proposal} as long as the Quote {Proposal} is received prior to the announced date and time for Quote {Proposal} submission. Vendors {Bidders} may refer to the QRG “Submit a Quote” for additional instruction. QRGs are located on the NJSTART Vendor Support Page.

Hard Copy: A Vendor {Bidder} may request that its hard copy Quote {Proposal} be withdrawn prior to the Quote {Proposal} opening. Such request must be made, in writing, to the Supervisor of the Proposal Review Unit at the address provided in Section 1.4.7.2 below. The Vendor {Bidder} may submit a revised Quote {Proposal} as long as the Quote {Proposal} is received prior to the announced date and time for Quote {Proposal} submission and at the place specified.

QUOTE {PROPOSAL} WITHDRAWAL AFTER QUOTE {PROPOSAL} OPENING, BUT PRIOR TO BLANKET P.O. {CONTRACT} AWARD

NJSTART and Hard Copy: If, after the Quote {Proposal} opening, but before Blanket P.O. {Contract} award, a Vendor {Bidder} discovers an error in its Quote {Proposal}, the Vendor {Bidder} may make a written request to the Supervisor of the Proposal Review Unit to withdraw its Quote {Proposal} from consideration for award. If the Vendor’s {Bidder’s} request to withdraw is made in good faith, and the State will not be significantly prejudiced by granting the withdrawal of the Quote {Proposal} beyond the loss of the benefit of the bargain to the State of the withdrawing Vendor’s {Bidder’s} offer, the request shall be granted. Evidence of the Vendor’s {Bidder’s} good faith in making this request can be demonstrated by one or more of the following factors: A mistake is so significant that to enforce the Blanket P.O. {Contract} resulting from the Quote {Proposal} would be unconscionable; that the mistake relates to a material feature or term of the Blanket P.O. {Contract}; and that the mistake occurred notwithstanding the Vendor’s {Bidder’s} exercise of reasonable care. After Quote {Proposal} opening, while pursuant to the provisions of this section a Vendor {Bidder} may request to withdraw its Quote {Proposal} and the Director may in her discretion allow said Vendor {Bidder} to withdraw it, the Division also may take notice of repeated or unusual requests to withdraw by a Vendor {Bidder} and take those prior requests to withdraw into consideration when evaluating the Vendor’s {Bidder’s} future Quotes {Proposals}.

All Quote {Proposal} withdrawal requests must include the Bid Solicitation {RFP} identification number and the final Quote {Proposal} submission date and be sent to the following address:

Department of the Treasury Division of Purchase and Property PO Box 039 33 West State Street – 9th Floor Trenton, New Jersey 08625-0039 Attention: Supervisor, Proposal Review Unit

If during a Quote {Proposal} evaluation process, an obvious pricing error made by a potential Blanket P.O. {Contract} awardee is found, the Director or her designee shall issue written notice to the Vendor {Bidder}. The Vendor {Bidder} will have up to five (5) business days after receipt of the notice to confirm its pricing. If the Vendor {Bidder} fails to respond, its Quote {Proposal} shall be considered withdrawn, and no further consideration shall be given to it.

If it is discovered that there is an arithmetic disparity between the unit price and the total extended price, the unit price shall prevail. If there is any other ambiguity in the pricing, other than a disparity between the unit price and extended price and the Vendor’s {Bidder’s} intention is not readily discernible from other parts of the Quote {Proposal}, the Director may seek clarification from the Vendor {Bidder} to ascertain the true intent of the Quote {Proposal}. If the Vendor {Bidder} inadvertently completes the “Discount” field and the “Unit Cost” field, the Discounted Unit Cost will prevail.

JOINT Venture

If a Joint Venture is submitting a Quote {Proposal}, the agreement between the parties relating to such Joint Venture should be submitted with the Joint Venture’s Quote {Proposal}. Authorized signatories from each party comprising the joint venture must sign the Offer and Acceptance Page {Signatory Page}. Each party to the Joint Venture must individually comply with all the forms and certification requirements in Sections 4.4.1 and 4.4.2 of this Bid Solicitation {RFP}.

Reciprocity for Jurisdictional Vendor {Bidder} Preference

In accordance with N.J.S.A. 52:32-1.4 and N.J.A.C. 17:12-2.13, the State of New Jersey will invoke reciprocal action against an out-of-State Vendor {Bidder} whose state or locality maintains a preference practice for its in-state Vendors {Bidders}. The State of New Jersey will use the annual surveys compiled by the Council of State Governments, National Association of State Procurement Officials, or the National Institute of Governmental Purchasing or a State’s statutes and regulations to identify States having preference laws, regulations, or practices and to invoke reciprocal actions. The State of New Jersey may obtain additional information as it deems appropriate to supplement the stated survey information.

A Vendor {Bidder} may submit information related to preference practices enacted for a State or Local entity outside the State of New Jersey. This information may be submitted in writing as part of the Quote {Proposal} response, including name of the locality having the preference practice, as well as identification of the county and state, and should include a copy of the appropriate documentation, i.e., resolution, regulation, law, notice to Vendor {Bidder}, etc. It is the responsibility of the Vendor {Bidder} to provide documentation with the Quote {Proposal} or submit it to the Director within five (5) business days after the deadline for Quote {Proposal} submission. Written evidence for a specific procurement that is not provided to the Director within five (5) business days of the public Quote {Proposal} submission date may not be considered in the evaluation of that procurement, but may be retained and considered in the evaluation of subsequent procurements.

QUOTE {PROPOSAL} ACCEPTANCES AND REJECTIONS

N.J.A.C. 17:12-2.7(d), the Director’s right to waive minor irregularities or omissions in a Quote {Proposal} and N.J.A.C. 17:12-2.2 which defines causes for Quote {Proposal} rejection, apply to all Quotes {Proposals}. In addition, pursuant to N.J.S.A. 52:34-12, the Director retains the right to reject all Quotes {Proposals} if it is in the public interest.

DEFINITIONS

CROSSWALK

General Definitions

The following definitions will be part of any Blanket P.O. {Contract} awarded or order placed as result of this Bid Solicitation {RFP}.

Definitions are listed by new NJSTART terminology; {existing terminology} appears in braces.

All-Inclusive Hourly Rate – An hourly rate comprised of all direct and indirect costs including, but not limited to: labor costs, overhead, fee or profit, clerical support, travel expenses, per diem, safety equipment, materials, supplies, managerial support and all documents, forms, and reproductions thereof. This rate also includes portal-to-portal expenses as well as per diem expenses such as food.

Best and Final Offer or BAFO – Pricing timely submitted by a Vendor {Bidder} upon invitation by the Bureau after Quote {Proposal} opening, with or without prior discussion or negotiation.

Bid or Bid Solicitation {RFP or Solicitation} – This series of documents, which establish the bidding and Blanket P.O. {Contract} requirements and solicits Quotes {Proposals} to meet the needs of the Using Agencies as identified herein, and includes the Bid Solicitation {RFP}, State of NJ Standard Terms and Conditions (SSTC), price schedule, attachments, and Bid Amendments {Addenda}.

Bid Amendment {Addendum} – Written clarification or revision to this Bid Solicitation {RFP} issued by the Division of Purchase and Property. Bid Amendments {Addenda}, if any, will be issued prior to Quote {Proposal} opening.

Business Day - Any weekday, excluding Saturdays, Sundays, State legal holidays, and State-mandated closings unless otherwise indicated.

Calendar Day – Any day, including Saturdays, Sundays, State legal holidays, and State-mandated closings unless otherwise indicated.

Change Order {Contract Amendment} – An alteration or modification of the terms of a Blanket P.O. {Contract} between the State and the Vendor(s) {Contractor(s)}. A Change Order {Contract Amendment} is not effective until it is signed and approved in writing by the Director or Deputy Director, Division of Purchase and Property.

Cooperative Purchasing Program – The Division’s intrastate program that provides procurement-related assistance to New Jersey local governmental entities and boards of education, State and county colleges and other public entities having statutory authority to utilize select State Blanket P.O.s {Contracts} issued by the Division, pursuant to the provisions of N.J.S.A. 52:25-16.1 et seq.

Days After Receipt of Order (ARO) - means the number of calendar days ‘After Receipt of Order’ in which the Using Agency will receive the ordered materials and/or services.

Director – Director, Division of Purchase and Property, Department of the Treasury, who by statutory authority is the Chief Contracting Officer for the State of New Jersey.

Discount - Means the standard discount applied by the Vendor {Bidder} to all items.

Discounted Unit Cost – Means “Unit Cost” field multiplied by (100 percent minus the “Discount” field percentage).

Division – The Division of Purchase and Property.

Evaluation Committee – A committee established or Division staff member assigned by the Director to review and evaluate Quotes {Proposals} submitted in response to this Bid Solicitation {RFP} and recommend a Blanket P.O. {Contract} award to the Director.

Firm Fixed Price – A price that is all-inclusive of direct cost and indirect costs, including, but not limited to, direct labor costs, overhead, fee or profit, clerical support, equipment, materials, supplies, managerial (administrative) support, all documents, reports, forms, travel, reproduction and any other costs.

Freight - Means Freight on Board (FOB) Destination.

Joint Venture – A business undertaking by two or more entities to share risk and responsibility for a specific project.

Master Blanket Purchase Order (“Blanket P.O.”) {Contract} – The Blanket P.O. {Contract} consists of the State of NJ Standard Terms and Conditions (SSTC), the Bid Solicitation {RFP}, the responsive Quote {Proposal} submitted by a responsible Vendor {Bidder} as accepted by the State, the notice of award, any Best and Final Offer, any subsequent written document memorializing the agreement, any modifications to any of these documents approved by the State and any attachments, Bid Amendment {Addenda} or other supporting documents, or post-award documents including Change Orders {Contract Amendments} agreed to by the State and the Vendor {Contractor}, in writing.

May – Denotes that which is permissible or recommended, not mandatory.

No Bid – The Vendor {Bidder} is not submitting a price Quote {Proposal} for an item on a price line.

No Charge – The Vendor {Bidder} will supply an item on a price line free of charge.

Ownership Disclosure Form – Refers to the Statement of Bidder/Vendor Ownership as utilized in NJSTART.

Primary Form – An electronic form contained within a Vendor’s {Bidder’s} NJSTART profile designated by the Vendor {Bidder} as the primary or principal version of the required form.

Procurement Bureau - The Division unit responsible for the preparation, advertisement, and issuance of Bid Solicitations {RFPs}, for the tabulation of Quotes {Proposals} and for recommending award(s) of Blanket P.O.(s) {Contract(s)} to the Director and the Deputy Director.

Project – The undertakings or services that are the subject of this Bid Solicitation {RFP}.

QRGs – Quick Reference Guides.

Quote {Proposal} – Vendor’s {Bidder’s} timely response to the Bid Solicitation {RFP} including, but not limited to, technical Quote {Proposal}, price Quote {Proposal}, and any licenses, forms, certifications, or other documentation required by the Bid Solicitation {RFP}.

Retainage - The amount withheld from the Vendor {Contractor} payment that is retained and subsequently released upon satisfactory completion of performance milestones by the Vendor {Contractor}.

Revision – A response to a BAFO request or a requested clarification of the Vendors {Bidders} Quote {Proposal}.

Shall or Must – Denotes that which is a mandatory requirement. Failure to meet a mandatory material requirement will result in the rejection of a Quote {Proposal} as non-responsive.

Should – Denotes that which is permissible or recommended, not mandatory.

Small Business – Pursuant to N.J.A.C. 17:13-1.2, “small business” means a business that meets the requirements and definitions of “small business” and has applied for and been approved by the New Jersey Division of Revenue and Enterprise Services, Small Business Registration and M/WBE Certification Services Unit as (i) independently owned and operated, (ii) incorporated or registered in and has its principal place of business in the State of New Jersey; (iii) has 100 or fewer full-time employees; and has gross revenues falling in one of the three following categories: For goods and services - (A) 0 to $500,000 (Category I); (B) $500,001 to $5,000,000 (Category II); and (C) $5,000,001 to $12,000,000, or the applicable federal revenue standards established at 13 CFR 121.201, whichever is higher (Category III); For construction services: (A) 0 to $3,000,000 (Category IV); (B) gross revenues that do not exceed 50 percent of the applicable annual revenue standards established at 13 CFR 121.201 (Category V); and (C) gross revenues that do not exceed the applicable annual revenue standards established at CFR 121.201, (Category VI).

State – The State of New Jersey.

State Contract Manager or SCM – The individual, as set forth in Section 8.0, responsible for the approval of all deliverables, i.e., tasks, sub-tasks or other work elements in the Scope of Work. The SCM cannot direct or approve a Change Order {Contract Amendment}.

Subtasks – Detailed activities that comprise the actual performance of a task.

Subcontractor – An entity having an arrangement with a Vendor {Contractor}, whereby the Vendor {Contractor} uses the products and/or services of that entity to fulfill some of its obligations under its State Blanket P.O. {Contract}, while retaining full responsibility for the performance of all [the Vendor’s {Contractor's}] obligations under the Blanket P.O. {Contract}, including payment to the Subcontractor. The Subcontractor has no legal relationship with the State, only with the Vendor {Contractor}.

Task – A discrete unit of work to be performed.

Unit Cost – All-inclusive, firm fixed price charged by the Vendor {Bidder} for a single unit identified on a price line.

Using Agency[ies] – A State department or agency, a quasi-State governmental entity, or a Cooperative Purchasing Program participant, authorized to purchase products and/or services under a Blanket P.O. {Contract} procured by the Division. In addition, with the approval of the Director of the Division of Purchase and Property and the agreement of the Vendor {Contractor}, the Blanket P.O. {Contract} may be used by any Using Agency or quasi-State governmental entity.

Vendor {Bidder} – An entity offering a Quote {Proposal} in response to the Division’s Bid Solicitation {RFP}.

Vendor {Contractor} – The Vendor {Bidder} awarded a Blanket P.O. {Contract} resulting from this Bid Solicitation {RFP}.

BLANKET P.O. {contract}-specific definitions/ACRONYMS

Aggregated Dispute Amount - The disputed payment amount may be aggregated by carrier and covered person or aggregated by carrier and CPT code in order to achieve the $1,000 threshold.

Arbitration - Process of determining a payment dispute between a payer and a provider by one or more impartial persons for a final and binding determination, in accordance with the Act.

Arbitration Organization - Nationally recognized, independent organization that specializes in arbitration with which DOBI has contracted for the purpose of conducting an arbitration proceeding and making a determination.

Arbitration Threshold – Payment amount in dispute of at least $1,000 by carrier and covered person or by carrier and Current Procedural Terminology ("CPT") code for all plans issued by that carrier. This excludes any payments previously made or received that are not in dispute.

Arbitrator - Individual employed by the arbitration organization who is responsible for conducting an arbitration proceeding and making a determination.

Carrier - Hospital service corporation, medical service corporation, health service corporation, health insurance company, or health maintenance organization.

Claim or Insured Claim - Claim by a covered person and/or provider for payment of benefits under a policy or contract issued by a payer for which the financial obligation for the payment of a claim under the policy or contract rests with the carrier.

Covered Person - Person on whose behalf a carrier offering the plan is obligated to pay benefits or provide services pursuant to the health benefits plan.

DOBI - Department of Banking and Insurance.

Dispute - Payment issue that remains unresolved following an internal appeal between the carrier and the provider.

Health Benefits Plan - Benefits plan that pays or provides hospital and medical expense benefits for covered services, and is delivered or issued for delivery in New Jersey by or through a carrier. A health benefits plan includes, but is not limited to, Medicare supplement coverage and Medicare+Choice contracts to the extent not otherwise prohibited by federal law. A health benefits plan shall not otherwise include the following plans, policies or contracts: accident only, credit disability, long-term care, Civilian Health and Medical Program for the Uniformed Services (CHAMPUS) , CHAMPUS supplement coverage, coverage arising out of a workers' compensation or similar law, automobile medical payment insurance, personal injury protection insurance issued pursuant to N.J.S.A. 39:6A-1 et seq., or hospital confinement indemnity coverage.

Health Care Provider or Provider - Individual or entity which, while acting within the scope of its license or certification, provides a covered service or supply as defined by the health benefits plan. Health care provider includes, but is not limited to, a physician and other health care professional licensed pursuant to Title 45 of the Revised Statutes, and a hospital and other health care facilities licensed pursuant to Title 26 of the Revised Statutes.

Hospital - General acute care facility licensed by the Commissioner of Health and Senior Services pursuant to N.J.S.A. 26:2H-1 et seq., including rehabilitation, psychiatric and long-term acute care facilities.

Program for Independent Claims Payment Arbitration (PICPA) - The PICPA is a program established by the Health Claims Authorization, Processing and Payment Act (HCAPPA) . It is designed to provide health care providers and carriers offering health benefits plans and independent body able to arbitrate claims disputes between a payer and a health care provider. The Department of Banking and Insurance (DOBI) contracts with an independent arbitration organization to perform the arbitration and related administrative functions.

Medical Necessity or Medically Necessary - A health care service that a health care provider, exercising his/her prudent clinical judgment, would provide to a covered person for the purpose of evaluating, diagnosing or treating an illness, injury or disease or its symptoms, in accordance with generally accepted standards of medical practice, clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for the covered person's illness, injury or disease. Further, the service is not primarily for the convenience of the covered person or the health care provider and not more costly than an alternative service or sequence of services and at least as likely to produce equivalent therapeutic or diagnostic results as is the diagnosis or treatment of that covered person's illness, injury or disease.

Payer - Carrier which requires or authorizes the approval of a health care service and includes an organized delivery system that is certified or licensed pursuant to N.J.S.A. 17:48H-1 et seq.

Pro Forma – Refers to template correspondence that includes standard text content.

SCOPE OF WORK

All requests shall be submitted in accordance with the required timeframes detailed in this Bid Solicitation {RFP} or requested by the SCM. Disputed payment amounts shall meet or exceed the $1,000 arbitration threshold, and the health benefits plan shall be an insured plan issued in New Jersey.

VENDOR {Contractor} Requirements

A. The Vendor {Contractor} must have the capacity to accept requests for arbitration and the arbitration fees electronically;

B. The Vendor {Contractor} shall collect and process fees in accordance with Section 3.1.6 below;

C. The Vendor {Contractor} shall complete a review of the request for arbitration submitted by the initiating party pursuant to Section 3.1.5 below;

D. The Vendor {Contractor} shall perform the arbitration proceeding based on the documentation submitted. There will be no in-person or telephonic hearings conducted;

E. The Vendor {Contractor} shall conduct an arbitration review, issue a determination, and communicate its findings electronically to DOBI, with complete statements of the issues, findings, and conclusions on which the determination is based, and the medical or other support; therefore, within 30 days after receipt of the required documentation necessary to make a determination;

F. The Vendor {Contractor} shall release its decision to the provider and payer electronically. At DOBI’s option, review of the arbitrator’s findings may be waived;

G. The determination is binding and non-appealable;

H. If the determination favors the initiating party, payment of the award must be made by the payer within ten (10) business days of the date of the determination;

I. If the arbitrator determines that a payer has withheld or denied payment of the claim in violation of the provisions of the Act, the arbitrator shall order the payer to make payment of the claim, together with accrued interest of 12% from the date the appeal was received by the payer;

J. If the arbitrator determines that a payer has withheld or denied payment of the claim on the basis of information submitted by the health care provider, but it did not receive all the required information when the claim was initially reviewed or pursuant to the internal claims appeals process, the payer shall not be required to pay accrued interest;

K. If the arbitrator determines that the provider engaged in a pattern and practice of improper billing and a refund is due to the payer, the arbitrator may award the payer a refund including interest at 12% per annum accrued from the date the appeal was received by the payer; and L. The arbitrator shall not award legal fees or costs.

timeliness of request for binding arbitration

The Vendor {Contractor} shall reject a request for arbitration when such a request is made in excess of 90 days after the provider’s receipt of the payer’s written determination on the internal claims appeal, or in excess of 90 days after the date that a payer’s determination of the provider's internal claims appeal was due where a payer has not provided a written notification on the provider's internal claims appeal. Proof of the payer’s receipt of a claims appeal is required, either by certified mail receipt or other delivery method showing date of actual receipt. If a timely request for arbitration has been rejected for insufficient information, a resubmitted request is deemed timely if received within 15 calendar days of the issuance of the rejection; no additional fee is required from the initiating party. If a timely request for arbitration is resubmitted with all the required information greater than 15 calendar days after the issuance of a rejection for insufficient information, the Vendor {Contractor} may impose an additional review fee on the initiating party not to exceed an additional one-half of the review fee. If the Vendor {Contractor} rejects the resubmitted request for arbitration, an initiating party must submit a new filing for consideration. A new filing made in excess of 90 days after the provider's receipt of the payer’s claims appeal determination shall be rejected as untimely.

aggregated dispute amount

The Vendor {Contractor} shall consider the following two (2) threshold dollar amounts when determining the aggregation of claims:

A. The Vendor {Contractor} shall reject a request for arbitration when such a request is made for a disputed payment amount less than $1,000. However, the disputed payment may be aggregated by carrier and covered person or aggregated by carrier and CPT code in order to achieve the $1,000 threshold. Other aggregation methods are not acceptable, and the Vendor {Contractor} shall reject non-complying claims for purposes of satisfying the $1,000 threshold;

B. A filing by an initiating provider with aggregated disputed payment amounts greater than $2,000 by carrier and covered person or by carrier and CPT code shall be considered additional filings for purposes of fee calculations and may be adjudicated as separate arbitrations; and

C. A non-aggregated disputed payment amount equal to or greater than $1,000 shall be considered as a single filing for purposes of fee calculations.

carrier arbitration eligibility

The Vendor {Contractor} shall reject an application for binding arbitration where such a request is made with respect to a health benefits plan that was not delivered or issued for delivery in New Jersey or which involves a health benefit provided by a self-funded or federal plan except for Managed Medicaid.

arbitration dispute issue eligibility

The Vendor {Contractor} shall reject a request for arbitration where such a request is made regarding any payment dispute in which the dispute involves medical necessity or utilization management. Medical necessity and utilization management disputes shall be reviewed by the Independent Health Care Appeals Process (IHCAP), see definition of IHCAP in Section 2.2 of this Bid Solicitation {RFP}.

review of a request for arbitration

The Vendor {Contractor} shall conduct a review of the initiating party's arbitration request and accept it for processing if the Vendor {Contractor} determines that:

A. The service which is the subject of the arbitration reasonably appears to be a covered service under the health benefits plan which covers the covered person and the covered person was enrolled with the carrier at the time the service was rendered;

B. The initiating party has made reasonable efforts to comply with the internal claims appeal mechanism available;

C. The initiating party has provided all information required to conduct the review, including the completed arbitration request form, its attachments and a fully executed release signed by the covered person in the event that the covered person's confidential information will accompany the arbitration request;

1. The release will be in a form prescribed by DOBI, in accordance with applicable regulations, providing for the release of medical records to obtain any necessary medical records from the carrier and payer and any other relevant health care provider;

D. The aggregated payment amount in dispute of the claim(s), by carrier and covered person or by carrier and CPT code, is $1,000 or more as per Section 3.1.2 above;

E. The covered person's health benefits plan is or was delivered or issued for delivery in New Jersey and is not a self-funded or federal plan except for Managed Medicaid; and

F. An initiating party has included one-half of the review fee and one-half of the arbitration fee with his request for arbitration;

1. If one-half of the review fee and one-half of the arbitration fee is not included, the Vendor {Contractor} shall consider the arbitration request to be incomplete.

review and arbitration fees

A. The request for arbitration shall be accompanied by the initiating party’s full share of the review and arbitration fees. The Vendor {Contractor} shall retain the initiating party's review fee if arbitration requests are rejected, in whole or in part, based on information submitted by the initiating party; the arbitration fee submitted by the…