RFP26-233 Appendix D-Terminology.pdf

Solicitation #: RFP UHAA 2026000233 Page 1 of 1 Appendix D, Terminology

HCPF Solicitation #:

RFP UHAA 2026000233

HOSPITAL PORTAL TOOL

Appendix D

Terminology

Solicitation #: RFP UHAA 2026000233 Page 1 of 14 Appendix D, Terminology

SECTION 1.0 DEFINED TERMS

1.1. The following list is provided to assist the reader in understanding specifically defined terms used in this solicitation. Any term specifically defined in the body of the solicitation or in any other Appendix shall have the meaning attributed to it in that document.

1.1.1. Benefit — The health care items or services covered under a member health plan.

Covered Benefits and excluded services are defined in the health plan's coverage and administration documents.

1.1.2. BIDM — The Business Intelligence and Data Management (BIDM) system is the

Department’s business intelligence and data analytic tool. It incorporates the

Department’s core MMIS and supporting services (interChange), the Pharmacy

Benefits Management System (PBMS), and the Colorado Benefits Management

System (CBMS), and other State and non-State systems.

1.1.3. Business Day — Any day in which the State is open and conducting business, but shall not include Saturday, Sunday, or any day which the State observes one of the holidays listed in C.R.S. §24–11–101(1).

1.1.4. Business Interruption — Any event that disrupts the Contractor’s ability to complete the Work for a period of time, and may include, but is not limited to a Disaster, power outage, strike, loss of necessary personnel or computer virus.

1.1.5. Centers for Medicaid and Medicaid Services (CMS) - The United States federal agency that administers Medicare, Medicaid, and the State Children’s Health

Insurance Program.

1.1.6. Certified Financial Statements — Financial statements, along with accompanying notes, that have been prepared in accordance with Generally Accepted Accounting

Principles and that have been audited by an independent certified public accountant(s) in accordance with generally accepted auditing standards.

1.1.7. Child Health Plan Plus (CHP+) — Colorado’s public low-cost health insurance for certain children and pregnant women. It is for people who earn too much to qualify for Health First Colorado (Colorado's Medicaid Program), but not enough to pay for private health insurance.

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1.1.8. Closeout Period — The period beginning on the earlier of 90 days prior to the end of the last Extension Term or notice by the Department of its decision to not exercise its option for an Extension Term and ending on the day that the Department has accepted the final deliverable for the Closeout Period, as determined in the

Department-approved and updated Closeout Plan, and has determined that the closeout is complete.

1.1.9. Colorado interChange (iC) — The Department’s Medicaid claims payment system.

1.1.10. Colorado Healthcare Affordability and Sustainability Enterprise (CHASE) — The

Colorado Healthcare Affordability and Sustainability Enterprise Act of 2017, C.R.S.

§25.5-4-402.4.

1.1.11. Colorado Open Records Act (CORA) — The Colorado Open Records Act, §§24-72-

200.1, et seq., C.R.S.

1.1.12. Colorado Revised Statutes (C.R.S.) — The legal code of Colorado; the codified general and permanent statutes of the Colorado General Assembly.

1.1.13. Community Benefit Implementation Plan — A plan that satisfies the requirements of an implementation strategy as described in 26 CFR § 1.501(r)-3(c).

1.1.14. Community Health Needs Assessment — A community health needs assessment that satisfies the requirements of 26 CFR § 1.501(r)-3(b).

1.1.15. Consumer Price Index-Urban (CPI-U) — The Consumer Price Index for All Urban

Consumers published by the US Department of Labor, Bureau of Labor Statistics.

1.1.16. Contract — The agreement, including all attached Exhibits, all documents incorporated by reference, all referenced statutes, rules and cited authorities, and any future modifications thereto, that is entered into as a result of this solicitation.

1.1.17. Contract Funds — The funds that have been appropriated, designated, encumbered, or otherwise made available for payment by the State under the Contract resulting from this Solicitation.

1.1.18. Contractor — The individual or entity selected as a result of this solicitation to complete the Work contained in the Contract.

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1.1.19. Contractor Pre–Existing Material — Material, code, methodology, concepts, process, systems, technique, trade or service marks, copyrights, or other intellectual property developed, licensed or otherwise acquired by Contractor prior to the Effective Date of this Contract and independent of any services rendered under any other contract with the State.

1.1.20. Critical Access Hospital — A hospital qualified as a critical access hospital under 42

U.S.C. § 1395i-4(c)(2) and certified as a critical access hospital by the Colorado

Department of Public Health and Environment.

1.1.21. Data — State Confidential Information and other State information resources transferred to the Contractor for the purpose of completing a task or project assigned in the Statement of Work.

1.1.22. Deliverable — Any tangible or intangible object produced by Contractor as a result of the work that is intended to be delivered to the Department, regardless of whether the object is specifically described or called out as a “Deliverable” or not.

1.1.23. Department — The Colorado Department of Health Care Policy and Financing, a department of the government of the State of Colorado.

1.1.24. Disaster — An event that makes it impossible for Contractor to perform the Work out of its regular facility or facilities, and may include, but is not limited to, natural disasters, fire or terrorist attacks.

1.1.25. Disproportionate Share Hospital (DSH) Payment — Payment made to qualified hospitals that serve a disproportionate share of Medicaid and uninsured as required under 42 U.S.C. § 1396r-4.

1.1.26. Effective Date — The date on which the Contract resulting from this solicitation is approved and signed by the Colorado State Controller or designee, as shown on the

Signature and Cover Page for the Contract.

1.1.27. Exclusive Provider Organization (EPO) — A type of managed care health plan where members are not required to select a primary care provider or receive a referral to receive services from a specialist. EPOs will not cover care provided out-of-network except in an emergency.

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1.1.28. Federal Financial Participation (FFP) — Federal matching funds for State expenditures relating to assistance payments, administered under the authority of the Centers of Medicare and Medicaid Services, for certain social services, and State medical and medical insurance expenditures.

1.1.29. Fraud — An intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to that person or some other person and includes any act that constitutes fraud under any federal or state law.

1.1.30. General Hospital — A health facility that, under an organized medical staff, offers and provides twenty-four hours per day, seven days per week, inpatient services, emergency medical and surgical care, continuous nursing services, and necessary ancillary services, to individuals for the diagnosis or treatment of injury, illness, pregnancy, or disability. See 6 CCR 1011-1 Chapter IV 2.100 (9).

1.1.31. Goods — Any movable material to be acquired, produced, or delivered by Contractor which shall include any movable material acquired, produced, or delivered by

Contractor in connection with the Services.

1.1.32. Health First Colorado — Colorado’s Medicaid program.

1.1.33. Health Insurance Portability and Accountability Act (HIPAA) — The Health

Insurance Portability and Accountability Act of 1996, as amended.

1.1.34. Health Maintenance Organization (HMO) — a type of managed care health plan that limits coverage to providers who work for or contract with the HMO and requires selection of a primary care provider and referrals to receive services from a specialist. HMOs will not cover care provided out-of network except in an emergency.

1.1.35. Health Plan — an individual or group plan that provides, or pays the cost of, medical care.

1.1.36. Healthcare Affordability and Sustainability (HAS) Fee — established under the

Colorado Healthcare Affordability and Sustainability Enterprise Act of 2017 (C.R.S. §

25.5-4-402.4), authorizes the Colorado Healthcare Affordability and Sustainability

Enterprise (CHASE) within the Department of Health Care Policy and Financing

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(HCPF) to collect a fee—up to six percent of hospitals’ net patient revenues—to draw federal matching funds. These funds are used to increase Medicaid (Health First

Colorado) hospital payments, support quality incentive programs, expand coverage through Health First Colorado and CHP+, and reduce cost-shifting to private payers.

CHASE also provides hospitals with guidance on improving efficiency, adapting to policy changes, and implementing performance-based payment systems. Oversight is provided by a 13-member CHASE Board representing hospitals, insurers, consumers, and HCPF.

1.1.37. Hospital — means an institution that is (1) primarily engaged in providing, by or under the supervision of physicians, Inpatient medical or surgical care and treatment, including diagnostic, therapeutic and rehabilitation services, for the sick, disabled and injured; (2) licensed, when located in Colorado, as a Hospital by the Colorado Department of Public Health and Environment (CDPHE); and, when not located in Colorado, by the state in which it is located; and (3) certified for participation in the Centers for Medicare and Medicaid Services (CMS) Medicare program. Hospitals can have multiple satellite locations as long as they meet the requirements under CMS. There are 104 licensed hospitals in Colorado. 10 are

Psychiatric hospitals, six are Long-Term Care Hospital hospitals, and four are

Rehabilitation hospitals. The remaining 84 hospitals are either General hospitals or

General hospitals with a Critical Access certification.

1.1.38. Hospital Community Benefit Accountability (HCBA) — refers to Colorado’s framework for ensuring transparency, accountability, and community engagement in how nonprofit, tax-exempt hospitals invest in their communities. Since 1969, nonprofit hospitals have been required to provide “community benefits” as a condition of their federal tax exemption, including charity care, Medicaid shortfall, community health improvement, education, and research. Colorado legislation— beginning with HB19-1320 and expanded through HB23-1243—requires hospitals to complete regular Community Health Needs Assessments (CHNAs), annual Community

Benefit Implementation Plans, and public meetings to share community benefit activities, spending, and priorities. HB23-1243 strengthened these requirements by mandating expanded public notification, detailed reporting to the Department of

Health Care Policy and Financing (HCPF), and corrective action plans for

Solicitation #: RFP UHAA 2026000233 Page 6 of 14 Appendix D, Terminology noncompliance. Together, these measures promote greater transparency, public participation, and data-driven oversight of hospitals’ community investments through the HCBA program administered by HCPF.

1.1.39. Hospital DSH Hospital Limit — A hospital’s maximum allowable DSH payment eligible for Medicaid FFP allowed under 42 U.S.C. § 1396r-4.

1.1.40. Hospital Financial Transparency — refers to Colorado’s legislative framework requiring hospitals to disclose detailed financial, utilization, and organizational information to promote accountability and public understanding of hospital finances. Established through House Bill (HB) 19-1001, the initiative mandates that hospitals submit audited financial statements, Medicare cost reports, and data on expenditures, acquisitions, and affiliations to the Department of Health Care Policy and Financing (HCPF) for analysis and public reporting. HB23-1226 further expanded these requirements by requiring more timely and detailed reporting on cash transfers, profits, reserves, executive compensation, and mergers or acquisitions, while granting HCPF greater authority to request additional information and enforce compliance through corrective action plans. Together, these measures aim to improve transparency, assess the financial efficacy of Colorado hospitals, and strengthen public trust in the healthcare system.

1.1.41. Hospital Quality Incentive Payment (HQIP) — The payment to hospitals for improving health care and patient outcomes as authorized under C.R.S. §25.5-4-

402(3). HQIP is a component of CHASE.

1.1.42. Hospital Transformation Program (HTP) — A Department initiative to support hospital led projects that improve patient outcomes, lower Health First Colorado costs, accelerate hospitals’ organizational, operational, and systems readiness for value-based payment, and increase collaboration between hospitals and other providers.

1.1.43. Incident — Any accidental or deliberate event that results in or constitutes an imminent threat of the unauthorized access or disclosure of State Confidential

Information or of the unauthorized modification, disruption, or destruction of any

State Records.

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1.1.44. Inpatient CHASE Fee — An assessment on hospitals based on inpatient Managed Care

Days and Non-Managed Care Days, defined as permissible health care-related tax in

42 CFR §433.68.

1.1.45. Inpatient Upper Payment Limit — The maximum amount that Medicaid can reimburse a provider for inpatient hospital services and still receive FFP.

1.1.46. Interface – What will be the Department’s data collection, data storage system, file sharing system, and communication system for Providers.

1.1.47. Key Personnel — The position or positions that are specifically designated as such in the Contract.

1.1.48. Licensed Beds — The maximum number of beds a hospital can operate, as administered by the Colorado Department of Public Health & Environment.

1.1.49. Long-Term Care Hospital — A hospital licensed through the Colorado Department of

Public Health & Environment.

1.1.50. Managed Care Day — An Inpatient hospital day for which the primary payer is a managed care health plan, including HMO, PPO, POS, and EPO.

1.1.51. Medicaid Day — A Managed Care Day or Non-Managed Care Day for which the primary or secondary payer is Medicaid.

1.1.52. Medicaid Enterprise Solutions — The MMIS, PBMS, CBMS, and BIDM systems.

1.1.53. Medicaid Managed Care Day — A Managed Care Day for which the primary payer is

Medicaid.

1.1.54. Medicare Cost Report — The Medicare hospital cost report, form CMS 2552-96 or

CMS 2552-10, or any successor form created by CMS, and the annual required submission of worksheets and schedules by Medicare certified providers used for

Medicare reimbursement.

1.1.55. Member – Any individual enrolled in the Colorado Medicaid program or Colorado’s

CHP+ program, as determined by the Department.

1.1.56. Negotiated Proposal — The final proposal document that was negotiated between

Offeror and the Department and submitted by Offeror for final consideration for

Solicitation #: RFP UHAA 2026000233 Page 8 of 14 Appendix D, Terminology award. Offeror - Any entity that submits a proposal, or intends to submit a proposal, in response to this solicitation.

1.1.57. Net Patient Revenue (NPR) Limit — The maximum amount of Inpatient and

Outpatient CHASE fees that can be assessed by the Department, pursuant to 42 CFR

§433.68 (f)(3)(i)(A).

1.1.58. Non-Managed Care Day — An inpatient hospital day for which the primary payer is an indemnity insurance plan or other insurance plan not services HMO, PPO, POS, or

EPO.

1.1.59. Offeror — Any individual or entity that submits a proposal, or intends to submit a proposal, in response to this solicitation.

1.1.60. Operational Start Date — The later of July 1, 2027, or when the Department authorizes the Contractor to begin fulfilling its obligations under the Contract.

1.1.61. Other Personnel — Individuals and Subcontractors, in addition to Key Personnel assigned to positions to complete tasks associated with the Work.

1.1.62. Outpatient CHASE Fee — An assessment on hospitals based on outpatient hospital charges, defined as permissible health care-related tax in 42 CFR §433.68.

1.1.63. Outpatient Upper Payment Limit — The maximum amount that Medicaid can reimburse a provider for outpatient hospital services and still receive FFP.

1.1.64. Other Personnel — Individuals and Subcontractors, in addition to Key Personnel assigned to positions to complete tasks associated with the Work.

1.1.65. Patient Days — Represent the total number of days patients spend in a Hospital or healthcare facility over a specific period. It is calculated by totaling the number of inpatients each day, where a partial day (including the day of admission) counts as a full day, and the discharge day is not counted.

1.1.66. Payer Group — The type of health insurance or coverage. This includes the following: commercial insurers, Medicare, Medicaid, individuals who self-pay, and a financial assistance plan.

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1.1.67. Payment Card Information — Payment card information, including any data related to credit card holders’ names, credit card numbers, or the other credit card information as may be protected by state or federal law.

1.1.68. Pediatric Specialty Hospital — A hospital that provides care exclusively to pediatric populations.

1.1.69. Personally Identifiable Information — Personally identifiable information including, without limitation, any information maintained by the State about an individual that can be used to distinguish or trace an individual’s identity, such as name, social security number, date and place of birth, mother’s maiden name, or biometric records; and any other information that is linked or linkable to an individual, such as medical, educational, financial, and employment information. PII includes, but is not limited to, all information defined as personally identifiable information in

§24–72–501 C.R.S.

1.1.70. Point of Service (POS) — a type of managed care health plan that charges patients less to receive services from providers in the plan’s network and requires a referral from a primary care provider to receive services from a specialist.

1.1.71. Portal Tool — a secure, web-based platform created and maintained by Contractor to serve as the primary interface between the Department, Hospitals, and Providers for the purposes of data collection, data analytics, data storage, file sharing, and reporting across multiple Hospital and Provider financing and transparency programs.

1.1.72. Preferred Provider Organization (PPO) — a type of managed care health plan that contracts Providers to create a network of participating providers. Patients are charged less to receive services from providers that belong to the network and may receive services from Providers outside the network at an additional cost.

1.1.73. Protected Health Information — Any protected health information, including, without limitation any information whether oral or recorded in any form or medium:

(i) that relates to the past, present or future physical or mental condition of an individual; the provision of health care to an individual; or the past, present or future payment for the provision of health care to an individual; and (ii) that identifies the individual or with respect to which there is a reasonable basis to

Solicitation #: RFP UHAA 2026000233 Page 10 of 14 Appendix D, Terminology believe the information can be used to identify the individual. PHI includes, but is not limited to, any information defined as Individually Identifiable Health

Information by the federal Health Insurance Portability and Accountability Act.

1.1.74. Provider — Any health care professional, hospital, or entity that has been accepted in the Colorado Medicaid program or Colorado’s CHP+ program, as determined by the Department.

1.1.75. Psychiatric Hospital — a health facility planned, organized, operated, and maintained to provide facilities, beds, and services over a continuous period exceeding 24 hours to individuals requiring early diagnosis and intensive and continued clinical therapy for mental illness. Services, including but not limited to, inpatient services, continuous nursing services, and necessary ancillary services, shall be provided twenty-four hours per day, seven days per week. See 6 CCR 1011-

1 Chapter 18 2(1).

1.1.76. Rehabilitation Hospital — A facility that is intended to provide a community with a type of facility, licensed as a hospital, capable of rendering quality service to those patients not acutely ill and not requiring surgical, intensive, maternity, or extensive radiological or clinical laboratory services, on a direct admission thereto or as a secondary referral admission subject to the clinical judgment of attending physicians, and who may, therefore, receive a relatively high level of special medical and nursing care directed primarily to a rehabilitative or restorative process commensurate with the individual clinical diagnosis. In general, but subject to specific conditions governing a particular facility within a given community, it is intended that a rehabilitation hospital offer its services on the basis of a full spectrum of community need without singular identification with any specific age groups or economic status of patients served. See 6 CCR 1011-1 Chapter 20 2.101

(8).

1.1.77. Services — The services to be performed by Contractor as set forth in this

Solicitation and shall include any services to be rendered by Contractor in connection with the Goods.

1.1.78. Start–Up Period — The period starting on the later of April 1, 2027 or the Effective

Date and ending on the Operational Start Date.

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1.1.79. State — The State of Colorado, acting by and through any State agency.

1.1.80. State Confidential Information — Any and all State Records not subject to disclosure under CORA. State Confidential Information shall include, but is not limited to, PII, PHI, PCI, Tax Information, CJI, and State personnel records not subject to disclosure under CORA. State Confidential Information shall not include information or data concerning individuals that is not deemed confidential but nevertheless belongs to the State, which has been communicated, furnished, or disclosed by the State to

Contractor which (i) is subject to disclosure pursuant to CORA; (ii) is already known to Contractor without restrictions at the time of its disclosure to Contractor; (iii) is or subsequently becomes publicly available without breach of any obligation owed by Contractor to the State; (iv) is disclosed to Contractor, without confidentiality obligations, by a third party who has the right to disclose such information; or (v) was independently developed without reliance on any State Confidential

Information.

1.1.81. State Fiscal Rules — The fiscal rules promulgated by the Colorado State Controller pursuant to C.R.S. §24–30–202(13)(a).

1.1.82. State Fiscal Year — The 12-month period beginning on July 1 of each calendar year and ending on June 30 of the following calendar year. If a single calendar year follows the term, then it means the State Fiscal Year ending in that calendar year.

1.1.83. State Records — Any and all State data, information, and records, regardless of physical form, including, but not limited to, information subject to disclosure under

CORA.

1.1.84. Statement of Work — The portion of the Contract that describes the specific requirements of the project described in this RFP, including all functional and operational requirements that the Department will use to measure the Contractor’s performance.

1.1.85. Structured Query Language (SQL) — The standard language for interacting with databases. It allows users to execute queries and perform operations such as accessing, creating, updating, and deleting data.

1.1.86. Subcontractor — Third-parties, if any, engaged by Contractor to aid in performance of the Work.

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1.1.87. Tax Information — Federal and State of Colorado tax information including, without limitation, federal and State tax returns, return information, and such other tax– related information as may be protected by federal and State law and regulation.

Tax Information includes, but is not limited to, all information defined as federal tax information in Internal Revenue Service Publication 1075.

1.1.88. Uninsured Cost — Uninsured days and charges allocated to routine and ancillary cost centers and multiplied by the most recent provider-specific per diem cost and cost-to-charge ratio from the Medicare Cost Report.

1.1.89. Upper Payment Limit (UPL) — See Inpatient Upper Payment Limit or Outpatient

Upper Payment limit.

1.1.90. Work — The delivery of the Goods and performance of the Services described in the

Contract.

1.1.91. Work Product — The tangible and intangible results of the Work, whether finished or unfinished, including drafts. Work Product includes, but is not limited to, documents, text, software (including source code), research, reports, proposals, specifications, plans, notes, studies, data, images, photographs, negatives, pictures, drawings, designs, models, surveys, maps, materials, ideas, concepts, know–how, and any other results of the Work. “Work Product” does not include any material that was developed prior to the Effective Date that is used, without modification, in the performance of the Work.

SECTION 2.0 ACRONYMS AND ABBREVIATIONS

2.1. The following list is provided to assist the reader in understanding certain acronyms and abbreviations used in this solicitation:

2.1.1. BIDM — Business Intelligence and Data Management

2.1.2. C.R.S. — Colorado Revised Statutes

2.1.3. CBMS — Colorado Benefits Management System

2.1.4. CDPHE — Colorado Department of Public Health and Environment

2.1.5. CFR — Code of Federal Regulations

2.1.6. CHASE — Colorado Healthcare Affordability and Sustainability Enterprise

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2.1.7. CHP+ — Child Health Plan Plus

2.1.8. CMS — Centers for Medicaid and Medicaid Services

2.1.9. CORA — Colorado Open Records Act, C.R.S. §24–72–200.1, et. seq.

2.1.10. CPI — Consumer Price Index

2.1.11. CPI-U — CPI for all urban consumers

2.1.12. DSH — Disproportionate Share Hospital

2.1.13. EPO — Exclusive Provider Organization

2.1.14. FFP — Federal Financial Participation

2.1.15. HAS — Healthcare Affordability and Sustainability

2.1.16. HCBA — Hospital Community Benefit Program

2.1.17. HCPF — Health Care Policy & Financing

2.1.18. HIPAA — Health Insurance Portability and Accountability Act of 1996, as amended.

2.1.19. HMO — Health Maintenance Organization

2.1.20. HQIP — Hospital Quality Incentive Payment

2.1.21. HTP — Hospital Transformation Program

2.1.22. iC — Colorado interChange

2.1.23. MES — Medicaid Enterprise System

2.1.24. MIDA — MES Integration Data and Alignment

2.1.25. MFCU — the Colorado Medicaid Fraud Control Unit in the Colorado Department of

Law

2.1.26. MMIS — Medicaid Management Information Systems

2.1.27. NPR — Net Patient Revenue Limit

2.1.28. PBMS — Pharmacy Benefits Management Services

2.1.29. PCI — Payment Card Information

2.1.30. PHI — Protected Health Information

2.1.31. PII — Personally Identifiable Information

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2.1.32. POS — Point of Service

2.1.33. PPO — Preferred Provider Organization

2.1.34. RFP — Request for Proposals

2.1.35. SFY — State Fiscal Year

2.1.36. SQL — Structured Query Language

2.1.37. U.S.C. — United States Code

2.1.38. UPL — Upper Payment Limit

2.1.39. VARA — Visual Rights Act of 1990