Attachment_2_Statement_of_Work_28pg.pdf

Attachment 2

Federal Bureau of Prisons Medical Claims Adjudication Services

Statement of Work

Objective

The primary objective of medical claims adjudication services, for healthcare service providers/contractors (healthcare providers) paid under Medicare-based rate structures, is to ensure compliance with Medicare Claims processing guidelines/manual in conjunction with the National Correct Coding Initiative edits; for fee schedule healthcare providers, the objective is to ensure compliance with the applicable negotiated fee schedule. In both cases, key considerations include avoidance of duplicate claims payments, erroneous claims and allowing the Bureau of Prisons (Bureau) to meet compliance requirements of the Prompt Payment Act and Statements of Federal Financial Accounting Standards (SFFAS).

Background

The Bureau currently provides healthcare to more than 160,000 inmates in more than 119 prisons (institutions) geographically dispersed throughout the contiguous United States, Hawaii, and Puerto Rico. For the purpose of contract award, all federal inmates are considered to have a single benefit plan and are members of this plan. Inmate entitlement and access to healthcare benefits is applied universally throughout the Bureau system. There are no accumulators or capitation in the Bureau healthcare system. Inmates do not pay premiums, copayments (for the purpose of contract award), or deductibles.

Medical services rendered to all federal inmates are governed by federal law, Bureau policies/procedures, the Joint Commission on Accreditation of Healthcare Organization (JCAHO), Health Insurance Portability and Accountability Act (HIPAA) and American Corrections Association (ACA) standards.

Primary care is provided by Bureau staff physicians and mid-level practitioners.

In addition, each institution within the Bureau solicits comprehensive medical contracts, including but not limited to the facilities referenced under Place of Service Codes in the CPT manual (see Attachment A)facility and physician services, based on the prevailing: 1) Federal Operating Rate Medicare rates for the applicable area for inpatient facility services;

2) Medicare fee schedule amounts for the area for outpatient facility services; 3) Skill nursing facilities, and 4) Medicare fee schedule amounts for the area for physician services. Healthcare providers are allowed to propose a discount from or premium to those Medicare benchmarks, which are then negotiated by the Bureau. The Bureau has been successful in awarding a majority of comprehensive medical contracts based on these structured Medicare rates. However, there are locations where the Bureau has been unsuccessful in awarding contracts based on Medicare rates. In those cases, contracts are typically awarded at a percentage of billed charges or fee schedule. Only institutions with CMS contracts will participate in claims adjudication.

In summary, each institution has separate and unique contract(s) with healthcare providers in their area.

Therefore, the “network of healthcare providers” will be those healthcare providers with current Bureau contracts and agreements. These contracts and agreements will each have formally negotiated and specifically, documented contract payment rates.

The Bureau is the sole payer for all healthcare services rendered to Bureau inmates. The number of claims processed each year may vary based on healthcare services provided during the year. Furthermore, claim forms are specified by the individual medical services contract, may vary depending on the age of each contract. Claim forms are currently submitted on paper via U.S. Postal Service mail or other express delivery service, and/or electronically. Most healthcare providers are using electronic billing via ANSI 837 format as this is the industry standard. For the purpose of contract award, a claim for contracted healthcare services reimbursed using the Medicare model is defined as either: a current paper version of the UB04 or CMS-1500; or alternatively, electronic claims that conform to Medicare and Health Insurance Portability and Accountability Act(HIPAA) electronic billing standards (reference http://www.cms.hhs.gov/ElectronicbillingEDITrans/01 overview.asp) from a contracted facility, physician’s office, or other healthcare provider. A claim for all other contracted healthcare services (not using Medicare reimbursement model) is defined per the terms of the individual contract or agreement(s).

All processes and/or changes in processes will have prior approval of the COR and/or the Administrative Contracting Officer as appropriate.

http://www.cms.hhs.gov/ElectronicbillingEDITrans/01%20overview.asp http://www.cms.hhs.gov/ElectronicbillingEDITrans/01%20overview.asp

Systems and Software

Minimum System Features

The system used by the contractor to adjudicate claims shall be an automated system and have the capability, at a minimum, to generate Explanation of Benefits (EOBs) which indicate the correct payment amount for each claim based upon the contracted rates, identify large case management opportunities, integrate utilization review decision documentation, automatically “pend” claims for medical records review (for certain DRGs), and evaluate potential invoice (claim) error patterns across all healthcare providers (e.g., CMS PEPPER system).

The system will also attach a .pdf document of the EOB and claim to each individual episode of care within the claim system itself. The technical proposal shall at a minimum include screenshots demonstrating how they shall meet this requirement. EOBs shall include detailed information for each line item per claim with an appropriate explanation as to the logic supporting the payment recommendation. The contractor will also address how corrections and/or corrected claims will be addressed within the system with the vendor providing screenshots.

A preauthorization process shall also be incorporated into the system. The Bureau expects to locate a .pdf of the EOB, claim and authorization within one central location/system. Vendor shall provide notification of new/updated information to each institution as it is generated. At a minimum, EOBs shall contain, inmate name, register number, account number, claim number, Medicare allowed amount, DOS, HCPCS/CPT/ICD-9 code to include modifiers, units, claim amount, markup percentage and final payment recommendation amount and clear explanation(s) of processing logic along with date the claim was received by contractor and date processed. Explanations will be easily understood by Bureau staff that does not specialize in Medicare claims processing. The contractor will also demonstrate how adjustments will be reflected on an EOB. The proposal should include examples of proposed EOBs, and shall not exceed seven pages.

Inmate Movement

Inmate location and demographic data will be submitted to the contractor via SENTRY feeds transmitted nightly by IPPA. It is expected the contractor will have the technical infrastructure to accept this information systematically. This system will be updated by the contractor daily to accurately reflect inmate location in real time.

Proposal submitted by vendor must specifically address, in detail, how the above requirement(s) will be fulfilled, and shall not exceed three pages.

Invoicing of Medical Services (Claims)

Electronic data interchange (EDI) of claims between the healthcare providers and the contractor will be required.

Claims are to be itemized and provide the detail necessary to facilitate the adjudication of the claims. The contractor shall provide the Bureau with a copy (can be electronic) of the original claim and an explanation of benefits (EOB) in lay terms for the Bureau to process payments. Additionally, the claim submission summary (or similar report) with notification of acceptance/rejection sent to the health care provider shall also be copied to the appropriate institution.

Proposal submitted by vendor must specifically address, in detail, how the above requirement(s) will be fulfilled, and shall not exceed two pages.

Interoperability

The proposed system must meet the following technical requirements. A product that meets these requirements will permit the Bureau to effectively manage and support the system with a minimum of information systems staff and ensure that all data maintained in the system is properly safeguarded. To satisfy this requirement, the system must:

A. Support a centralized architecture with a centralized database which is intranet/Internet accessible.

B. Support secure file transfers of medical claims, EOBs and GFE documents between the contractor and the Department of Justice’s MB system. However, the specific system utilized is subject to change secondary to DOJ system upgrades/changes/requirements. Support secure automated file transfers of inmate information from the Bureau’s mainframe system.

C. Allow Bureau Central Office Information Systems staff to manage and maintain, if necessary, the system from the Washington, DC, offices.

D. Function and provide adequate response times across wide-area network connections of three T-1 circuits to as fast as a DS-3 that are part of the Department of Justice’s JUTNET network. Each institution has a 10/100 megabit/second Ethernet network. The Central Office runs a 10/100/1000 megabit/second Ethernet network in its computer room.

E. Use the TCP/IP transport protocol.

F. Use Web-browser software compatible with the Window XP and Windows 7 operating system. The Bureau’s standard is Microsoft Internet Explorer 8.0.

G. Require a minimal client workstation hardware configuration that is sufficient to run Internet Explorer.

Current Bureau personal computers have Intel I7 CPUs running at 3.4GHz or better. They are configured with at least 4GB of memory or better.

H. Must be able to interoperate with other Bureau information systems such as the email system GroupWise (all emails containing PII shall be encrypted and the contractor all be able to send and receive encrypted email), network file server system from Novell, and our electronic medical and pharmacy systems.

The Contractor must be able to support any and all hardware and software installation that is necessary for the Bureau to connect to and use the new system.

Proposal submitted by vendor must specifically address, in detail, how the above requirement(s) will be fulfilled, and shall not exceed seven pages.

Provider Data Submission

The contractor will accurately maintain and update provider data submitted from the comprehensive medical contractors as defined in the CMS contracts (Attachment B). This includes, but is not limited to single practitioners, group practitioners, institutional providers, and Doing Business As (DBA) providers as required for HIPAA compliant claim submission as well as ensuring the appropriate

Medicare/contract rates are applied during the adjudication process. The proposal shall include the contractor’s plan to receive, update and maintain this information, i.e., web-based, spreadsheet, etc.

Proposal submitted by vendor must specifically address, in detail, how the above requirement(s) will be fulfilled, and not exceed three pages.

Security Requirements

The proposed system must meet the following security requirement:

Provided security safeguards that are consistent with HIPAA.

Allow any stored data to be encrypted both in the database and while it is being transmitted on the local and wide-area networks.

Use role and policy-based user authentication and verification. User access must be restricted by user ID as well as the staff member’s location.

Provide audit trails for all record activity. Tools must be available to support the analysis of these audit trails.

Allow all security functions to be performed by facility, regional office, and Central Office staff for their respective levels of responsibility.

Proposal submitted by vendor must specifically address, in detail, how the above requirement(s) will be fulfilled, and shall not exceed seven pages.

Data

The contractor shall describe how the Bureau will have access to the data collected during the adjudication process, and include any costs of providing this service. However, as a condition of a contract, the contractor agrees the Bureau owns all data generated by the medical claims adjudication process and the Bureau will have access to the data. The contractor shall ensure all data files and formats will be sequential flat files containing ASCII character data to ensure compatibility with other Bureau data systems. The contractor shall also provide technical documentation regarding all data files and formats, as well as provide updated documentation as changes occur.

Proposal submitted by vendor must specifically address, in detail, how the above requirement(s) will be fulfilled, and shall not exceed three pages.

Requirements

Experience

The contractor must have specific experience in medical claims adjudication services required and requested in the SOW. The contractor shall have a minimum of five years of proven, past experiences in this field to perform the services in accordance with the SOW. Proposal submitted by vendor addressing this item and will not exceed one page.

Compliance

The contractor must ensure medical claims are adjudicated in accordance with current National Correct Coding Initiative edits in conjunction with Medicare/CMS claims processing guidelines and/or negotiated fee schedules, as applicable to underlying contracts.

The contractor shall also incorporate internal and systemic controls in the adjudications process to preclude duplicate payments and ensure that the Bureau complies with the requirements of the Prompt Payment Act and SFFAS.

The contractor shall provide a Health Insurance Portability and Accountability Act (HIPAA) compliance plan, and designate a compliance officer with an extensive background/training regarding this requirement.

Proposal submitted by vendor must specifically address, in detail, how the above requirement(s) will be fulfilled, shall not exceed three pages, and include a resume for the proposed compliance officer.

Authorizations

The contractor shall describe how they will integrate an authorization process into their claims adjudication system to include a .pdf of the form. The contractor shall include specific details on how authorization would be delivered, entered into their system, and tracked. With the exception of the standard outpatient surgical package (i.e., preoperative anesthesia assessment, procedure, and postoperative follow-up), blanket or continuing authorization will not be given.

Each episode of care for contracted specialty physician, outpatient, and inpatient hospital services shall be authorized by the institutions. All Medicare-based services provided on-site at a Bureau facility are to be authorized.

The Bureau shall provide (scan and deliver via encrypted email) the following data elements commonly found on the UB04 upon initiation of authorization process:

Provider name and address. It shall be the responsibility of the contractor to keep a list of provider tax ID numbers to match with incoming claims.

Inmate federal register number. This will serve as insured’s identification number.

Inmate first and last name.

Patient’s relationship to insured shall always be self.

Inmate’s address (institution at date of service).

Inmate’s date of birth.

Expected date(s) of service.

Payer (name of specific Bureau institution). Payer address shall be the same as the inmate’s address.

Provide update of patient status, i.e., change from outpatient to inpatient, expanded scope of services, to the contractor.

In the event, Case-by-Case pricing is agreed upon by the institution for a particular episode of care, the contractor will be notified in advance of the agreed upon rate.

B. The institution shall provide a general description of requested medical service (i.e., consultation request to a specific healthcare provider for treatment of a given diagnosis).

C. Type of service (i.e., inpatient versus outpatient consultation or surgery) shall be correctly inferred by the contractor from description provided by institution.

D. Based on authorization information, the contractor shall provide, within three (4) business days of receiving a authorization, a good faith estimate (GFES)of the expected costs of the service. For example, for inpatient admissions, the contractor shall provide estimated DRG and expected reimbursement rate for that DRG; for outpatient services, the contractor shall provide estimated evaluation and management costs associated with consultation to specialty provider and typical outpatient procedure costs for a given category/group of procedures.

Cost estimates shall include all anticipated ancillary bills outside main facility billing (i.e., physician and laboratory/pathology in addition to surgical facility/hospital billing). Upon receipt of updated information from the institution, the contractor shall generate a new GFE and return to the Bureau within four (4) days. The contractor shall continually refine their cost estimation process to provide increasing accuracy of estimates.

E. New and/or updated authorizations will be required; this will include authorizations from information that may be received by the contractor after the date of service (i.e., admissions after normal duty hours, status change from ER visit to inpatient status, change in medical condition, etc.).

Upon receipt of new and/or updated information from the institution, the contractor shall also generate a new and/or updated GFE, and return to the Bureau within four (4) days.

F. Bureau staff will not manually enter authorization information into an authorization system; it is expected the contractor will complete this task.

GFEs will be submitted electronically to the DOJ MB system in .pdf format. However, the specific system utilized is subject to change secondary to DOJ system upgrades/requirements.

Proposal submitted by vendor must specifically address, in limited to five pages.

Technical Point of Contact

The contractor shall assign a technical point of contact.

This individual shall be the point of contact between the contractor, the contracting officer representative (COR), and the Bureau. The POC shall contact the COR when required and shall coordinate any training and site visits to the institutions. The contractor also will submit expected staffing levels, i.e., organizational charts, to demonstrate the ability to support the Bureau workload. In the event the primary technical point of contact is unavailable/out of the office during normal business hours, the contractor shall provide an alternate; the alternate will be available during established business hours.

Proposal submitted by vendor must specifically address, in detail, how the above requirement(s) will be fulfilled, and limited to five pages to include an organizational chart.

Implementation and Training

The Contractor shall describe how it would implement its services and train Bureau staff in the use of the bill adjudication system. The Contractor will provide a firm fixed per claim price, inclusive of any and all training and one-time start-up costs.

A. The Bureau expects initial training on-site at each individual institution. Institutions currently participating in claims adjudication are to receive training first. The technical proposal will outline a training plan and schedule for the remaining institutions. The schedule will be coordinated with the COR and the Bureau will have final approval.

B. Annual refresher training will be provided to update Bureau staff on any changes regarding the claims system, Medicare claims processing changes which will affect adjudication. Refresher training may be via distance, i.e., online, video conference. An implementation schedule will be setup at the beginning of each option period.

C. Contractor will provide institution-specific reference manuals to each site on the medical claim adjudication process. All manuals shall be current, and notification shall be made by the contractor to the appropriate Bureau staff regarding any updates and/or revisions. Technical manuals will be available in an electronic format that is searchable.

Manuals will also be sent periodically at the request of an institution. The technical proposal shall include an example of a manual.

D. The technical proposal shall include a step-by-step plan for implementation at the institutions currently participating in claims adjudication as well as a plan for the remaining institutions.

There will be a 90-day implementation phase, beginning on the award date, to include:

Within five (5) working days after award: The Bureau will schedule a meeting with the incoming contractor and the Bureau to determine any legal and logistical requirements, i.e., trade partner agreements, points of contact, business requirements, etc.

Within 10 workings days after award of contract: The Bureau, contractor and comprehensive medical services contractor shall meet to discuss technical requirements, EDI information/submission and other business items.

Within 30 working days after award of contract: Contractor shall accept and input provider data submitted by comprehensive medical services contractors and complete EDI submission testing.

Within 60 working days after award of contract: Contractor will complete on-site training at the institutions currently participating in claims adjudication. After completion of training, institutions will send authorization information and contractor will start generating GFEs.

90 days from award of contract: The contractor shall be fully operational and in compliance with all contract requirements.

Proposal submitted by vendor must specifically address, in detail, how the above requirement(s) will be fulfilled, and shall not exceed three pages.

Transition Timeline and Procedures

End of Contract Transition

If the solicitation is awarded to the previous contractor the following should happen:

Within 14 working days of the new contract award the Bureau will schedule a meeting to review the changes to apply to the new contract with the incumbent contractor and will define a mutually agreed upon timeline between the Bureau and the incumbent contractor to implement any new contract regulations, system changes or line items.

Transition-Out to New Contractor

If the solicitation is awarded to a new contractor, the following should happen:

The current contractor will transition the contract to the new contractor via a mutually agreed upon format. The claims history developed for the outgoing contract will need to be electronically passed to the new contractor. There will be a 90-day transition-out phase, beginning on the award date, to include:

Within 5 working days after award date: The Bureau will schedule a meeting between the out-going contractor, the Bureau, and incoming contractor to define file format to submit claims history to new contractor.

Daily: The out-going contractor shall submit claims history updates in defined file formats to the new contractor daily from date agreed upon during the transition meeting through end of contract.

Within 10 working days after award date: The out-going contractor shall submit claims history for the contract lifecycle to the new contractor.

The Bureau will notify the institutions with the new contractor information and instructions, as well as the end date for claims to be submitted to the out-going contractor.

Ten working days prior to the end of contract: The out-going contractor shall complete all claims, adjustments, and corrected claims.

Three working days prior to the end of contract: The out-going contractor shall complete all GFES wrap-ups.

The last day of the contract: The out-going contractor shall turn off all external access to incumbent systems and all phones.

Within 5 working days after the last date of the contract: The out-going contractor shall return to the submitter(s) any new claims, adjustments, and corrected claims received on or after the end of contract.

Within 14 working days after the end of contract: The out-going contractor shall submit a final bill to the Bureau. The Bureau will pay the outgoing contractor’s final bill in accordance to prompt pay.

The Contractor will provide one transitional cost to cover the necessary process above.

Proposal submitted by vendor must specifically address, in not exceed three pages.

Quality Assurance

As a condition of a contract, the contractor agrees to be subject to unannounced and recurring quality assurance reviews by the Bureau and/or its representative. This includes, but is not limited to a review of payment recommendations, good faith estimates, authorizations, training, and reporting. All correspondence to the Bureau and individual institutions should be clear, concise, and understandable. Any reports sent to the institution should also be sent to the COR. New procedures affecting the adjudication process should be conveyed to the Bureau in writing prior to implementation.

The Bureau and contractor shall agree to any such changes in writing prior to their implementation.

Any contractor processing errors, including but not limited to, incorrect application of contract rates, erroneous application of Medicare/NCCI edits, etc., shall be corrected/adjusted and a new payment recommendation generated at no charge to the Bureau. The contractor shall submit quarterly reports to the COR detailing any adjustments and errors.

Proposal submitted by vendor must specifically address, in detail, how the above requirement(s) will be fulfilled; this should include a sample and shall not exceed five pages.

Reports

The contractor shall provide the Bureau with the following reports, both at the individual institution level and Bureau wide, on a quarterly and as needed basis as determined by the Bureau:

Institution-specific Reports

Claims processing errors/adjustments.

Top 10 diagnosis codes.

Top 10 DRGs.

Top 10 reasons for claim denials.

Top 10 inpatient diagnosis codes.

Top 10 claims “line” denials.

Top 10 procedure codes.

Bureau wide Data Reports

Claims processing errors/adjustments.

Top 10 diagnosis codes.

Top 10 DRGs.

Top 10 reasons for claims denials.

Top 10 inpatient diagnosis codes.

Top 10 claim “line” denials.

Top 10 procedure codes.

Hospital readmission within 30 days for same diagnosis.

Top 10 adjusted claims (reason and facility vs. professional).

Claims greater than $35,000 for same diagnosis.

Claims by service location.

Number of facility claims per institution.

Number of professional service claims per institution (inpatient vs. outpatient).

Other reports will be required by the Bureau on an ad hoc basis. All requested ad hoc reports will be sent to the requesting party within three (3) business days. Individual institutions will request ad hoc reports through the COR. At a minimum reports will be available in .pdf, Excel and Word formats.

Proposal submitted by vendor must specifically address, in include sample reports, and shall not exceed 25 pages.

Administrative

Payment Schedules

Inmates are frequently transferred between institutions and, therefore, may have claims paid under different payment schedules. The schedule applied to the claim adjudicated shall correspond to the inmate’s location on the date of service (which would also be the institution giving preauthorization for services).

Inmate location and demographic data will be submitted to the contractor via SENTRY feeds transmitted nightly by IPPA. It is expected the contractor will have the technical infrastructure to accept this information systematically. This will be updated by the contractor daily to accurately reflect inmate location.

Healthcare providers utilizing fee schedule would vary (i.e., varying database formats, paper claims). For contracts based on Medicare rates, the CMS prospective payment system will be used to calculate reimbursement. The code sets used by healthcare providers shall be the ICD-10-CM (or most current version), CPT, and HCPCS codes for the year in which the episode of care was given.

Case by Case (CBC) is defined as a provider rendering medical services outside of the normal contract payment structure at a rate agreed upon by the Bureau. Bureau comprehensive medical contractors should be utilizing their contracted networks;

therefore, the instances of CBC pricing should be minimal.

However, the Bureau cannot guarantee a limited number of CBC claims as this is secondary to the needs of the institution and is subject to change. CBC rates should be submitted to the contractor by the institution prior to submission of such claims; however, the contractor is expected to contact the institution in an effort to obtain these CBC rates before manually or systematically denying these claims.

The proposal submitted by vendor must specifically address, in detail, how the above requirement(s) will be fulfilled, and shall not exceed five pages.

Prompt Payment Considerations

Immediately upon receipt of an invoice (claim) from a healthcare provider, the contractor shall date stamp the claim as received. The contractor shall not hold claims prior to date stamping for any reason as this is time sensitive secondary to the Prompt Pay Act. If the contractor receives an improper claim from the healthcare provider, or additional information is required to process the claim, the contractor shall notify the healthcare provider and/or institution within seven (7) days after receipt of the improper claim. Upon receipt of a proper claim, the contractor shall provide the Bureau institution making payment, a written EOB, within four

(4) working days.

Proposal submitted by vendor must specifically address, in detail, how the above requirement(s) will be fulfilled, and shall not exceed two pages.

Healthcare Provider Invoicing of Medical Services

The contractor shall not make payments for medical services rendered to Bureau inmates on behalf of the Bureau. Final decisions about payments will be made by the institutions.

The proposal will acknowledge understanding of this requirement.

Billing of Adjudication Services

The contractor shall bill each Bureau institution separately for adjudication services rendered based on the actual number of claims processed by the contractor for each institution.

Billing shall be done on a monthly or quarterly basis. All billing questions shall be directed to the institution directly. If the contractor is a Government agency, the contractor shall not submit billings through the Intragovernmental Payment and Collection (IPAC) system during the last three days of the month.

Special Security and Clearance Requirements

All contractor personnel shall have personnel security clearances commensurate with the highest level of information processed by the system(s) they use. The provisions of Department of Justice Order DOJ 2640.2F and the Federal Bureau of Prison’s Human Resource Management Manuel 3000.03 shall be followed in determining contractor security clearance levels and activities.

Contractor and subcontractor personnel working in computer system design, development and support, or maintenance positions shall have security investigations commensurate with the highest level of information processed by the system. The positions assumed by the contractor and subcontractor personnel may be categorized as one of the following:

Critical Sensitive.

Non-Critical Sensitive.

MT-Related Services – NON sensitive Data Access.

Each contractor employee with access to Bureau-Information Technology (IT) equipment shall have security investigations commensurate with the highest level of information processed by the system. The Human Resources Manager or Personnel Security Officer shall determine the level of security clearance required.

A critical-sensitive position will be required to have a full-field background investigation (BI), and a non-critical sensitive position will be required to have a limited background investigation (LBI), as defined in the Human Resources Management Manual . For those contractors who will not have access to sensitive data, appropriate security checks will be completed commensurate with Bureau security regulations.

NOTE: The Bureau may permit other Government security clearances to be substituted for the above background investigation, if determined by the Bureau to be equal, current, and provided the contractor submits adequate documentation to support the Bureau’s determination.

In addition to the aforementioned background investigations, the Bureau security requirements include, but are not necessarily limited to the following (NOTE: Requirements listed below are based on the level of security required):

National Crime Information Center (NCIC).

National Agency Check with Inquiries (NACI).

Law Enforcement Agency Checks.

National Law Enforcement Telecommunication (NLETS) Checks.

Credit checks.

Finger Print Check (FD-258).

Completed OF-306, Declaration of Federal Employment and Appropriate Resume and Optional Application.

Completed Contractor Pre-employment form.

Release of Information.

Urinalysis.

Employment Vouchering over the last five years.

Note: If a urinalysis test is required, the test will be administered at the closest Bureau facility where the work is to be performed. IF the test is positive for drug usage, the individual(s) assigned to perform the work shall be excluded and the contractor shall provide acceptable replacement personnel subject to the same security requirements.

Access to IT sensitive information will be based on the completion of successful background investigations and security clearances, to include the receipt of a National Agency Check with Inquiries (NACI) case number. Once a decision has been rendered by the Personnel Security Officer that contract personnel are suitable for access to the appropriate IT system, notification will be made in writing to the technical point of contact and the respective contracting officer. The contracting officer will then issue a Notice to Proceed and the contractor and subcontractor will then have the authority to commence contract performance.

DOJ Order 2640.2F – The Department of Justice does not permit the use of Non-U.S. citizens in the performance of this contract of commitment for any position that involves access to or development of any DOJ IT system, unless a waiver has been granted by the Department of Justice Chief Information Officer. By signing the contract document or beginning performance, the contractor agrees to this restriction.

Confidentiality and Non-Disclosure – The Contractor shall agree: all deliverables and associated working papers Contractor in the performance of this contract are the property of the U.S. Government.

The Contracting Officer’s Representative (COR) or his authorized designee shall be the sole authorized official to release verbally or in writing, any change in dated, the draft deliverables, the final deliverables or any other written or printed materials pertaining to this project. The Contractor shall release no information. Any request for information relating to this contract presented to the Contractor must be submitted to the COR or his designee for response.

Computer Room Requirements – The Contractor shall agree that any Contractor-owned facility housing Bureau sensitive information shall meet the requirements for Department of Justice computer rooms as per the Bureau program statement, Information Security, P1237.15.

Informational Requirements for Claims and EOBs

Comprehensive medical contractors are required to submit claims with the following information/formats. The claims system, including claims and EOBs, will mirror this requirement.

A. Inmate Bureau register number will be keyed with five digits, a hyphen, and three digits in the following format:

12345-678.

B. The invoice number transmitted in electronically submitted medical claims shall be referenced in the Patient Account Number field in the 2300 loop, CLM01 segment. In a UB-04 hard copy medical claims, the invoice number shall be included in the Patient Account Number field, block 3a. In a professional hardcopy medical claim submission, the invoice number shall be included in the Patient Account Number Field, block 26.

C. The invoice number will be limited to 13 characters;

Positions 1-3 will be the institution’s alpha facility code, positions 4-5 will be alpha/numeric and mutually agreed upon the institution and comprehensive contractor, and positions 6- 13 will be alpha/numeric and sequential. No special characters will be allowed.

Proposal submitted by vendor must specifically address, in shall not exceed 10 pages.

Quality Management

Customer Service

The contractor shall describe their customer support service program for institutions with questions about specific EOBs including, but not limited to, CBSA discrepancies, NCCI edits, Medicare claims processing guidelines, MPPRs, etc.) The vendor shall also describe support services available to comprehensive contractor regarding HIPAA critical issues and EDI rejections. Customer support must be provided during normal business hours (Monday-Friday, 7:30 am Eastern Time to 4:00 pm Hawaii-Aleutian Standard Time) for all institutions.

All queries must be responded to within 24 hours.

Proposal submitted by vendor must specifically address, in detail, how the above requirement(s) will be fulfilled, and shall not exceed five pages.

Fraud, Waste, and Abuse

The contractor shall describe and submit surveillance programs for detection and tracking of deliberate fraud and abuse (i.e., billing for services not likely to have been furnished as billed, misrepresenting the diagnosis to justify payment, deliberate unbundling). When a pattern of fraud and abuse is identified, the Bureau will be contacted immediately with a detailed report of the suspected issue.

Proposal submitted by vendor must specifically address, in detail, how the above requirement(s) will be fulfilled, and shall shot exceed three pages.

Period of Performance

The contract term will be for one 12-month base period and four 12-month option periods as follows:

Base Period: Date of Award through 12 months Option Period One: 13 Months through 24 months Option Period Two: 25 months through 36 months Option Period Three: 27 months through 48 months Option Period Four: 49 months through 60 months

Exclusions

Healthcare providers currently providing healthcare services to the Bureau under contract, purchase order, or other service agreement, whether directly and/or indirectly (as a third-party intermediary) are precluded from participating in this solicitation/contract.

Appendix

Appendix A: Place of Services Codes for Professional Claims Appendix B: List of Provider Information Requirements

Appendix A

Place of Service Codes for Professional Claims

Database (updated November 1, 2012) Listed below are place of service codes and descriptions. These codes should be used on professional claims to specify the entity where service(s) were rendered. Check with individual payers (e.g., Medicare, Medicaid, other private insurance) for reimbursement policies regarding these codes. If you would like to comment on a code(s) or description(s), please send your request to posinfo@cms.hhs.gov.

The code set is annotated with the effective dates for all codes added on and after January 1, 2003. Codes without effective dates are long-standing and in effect on and before January 1, 2003.

Place of Service Code(s)

Place of Service Name

Place of Service Description

Pharmacy

A facility or location where drugs and other medically related items and services are sold, dispensed, or otherwise provided directly to patients. (Effective October 1, 2005)

02 Unassigned N/A

03 School A facility whose primary purpose is education.

(Effective January 1, 2003)

Homeless Shelter

A facility or location whose primary purpose is to provide temporary housing to homeless individuals (e.g., emergency shelters, individual or family shelters). (Effective January 1, 2003)

Indian Health Service Free-standing Facility

A facility or location, owned and operated by the Indian Health Service, which provides diagnostic, therapeutic (surgical and non-surgical), and rehabilitation services to American Indians and Alaska Natives who do not require hospitalization.

Indian Health Service Provider-based Facility

A facility or location, owned and operated by the Indian Health Service, which provides diagnostic, therapeutic (surgical and non-surgical), and rehabilitation services rendered by, or under the supervision of, physicians to American Indians and Alaska Natives admitted as inpatients or outpatients. (Effective January 1, 2003) mailto:posinfo@cms.hhs.gov

Tribal 638 Free-standing Facility

A facility or location owned and operated by a federally recognized American Indian or Alaska Native tribe or tribal organization under a 638 agreement, which provides diagnostic, therapeutic (surgical and non-surgical), and rehabilitation services to tribal members who do not require hospitalization.

(Effective January 1, 2003)

08 Tribal 638 A facility or location owned and operated by a

Provider-based Facility federally recognized American Indian or Alaska Native tribe or tribal organization under a 638 agreement, which provides diagnostic, therapeutic (surgical and non-surgical), and rehabilitation services to tribal members admitted as inpatients or outpatients.

Prison/ Correctional Facility

A prison, jail, reformatory, work farm, detention center, or any other similar facility maintained by either Federal, State or local authorities for the purpose of confinement or rehabilitation of adult or juvenile criminal offenders.

(Effective July 1, 2006)

10 Unassigned

Office

Location, other than a hospital, skilled nursing facility (SNF), military treatment facility, community health center, State or local public health clinic, or intermediate care facility (ICF), where the health professional routinely provides health examinations, diagnosis, and treatment of illness or injury on an ambulatory basis.

Home

Location, other than a hospital or other facility, where the patient receives care in a private residence.

Assisted Living

Congregate residential facility with self-contained living units providing assessment of each resident’s needs and on-site support 24 hours a day, 7 days a week, with the capacity to deliver or arrange for services including some health care and other services.

(Effective October 1, 2003)

Group Home *

A residence, with shared living areas, where clients receive supervision and other services such as social and/or behavioral services, custodial service, and minimal services (e.g., medication administration).

Mobile Unit

A facility/unit that moves from place-to-place equipped to provide preventive, screening, diagnostic, and/or treatment services.

Temporary Lodging

A short term accommodation such as a hotel, camp ground, hostel, cruise ship or resort where the patient receives care, and which is not identified by any other POS code.

(Effective April 1, 2008)

Walk-in Retail Health Clinic

A walk-in health clinic, other than an office, urgent care facility, pharmacy or independent clinic and not described by any other Place of Service code, that is located within a retail operation and provides, on an ambulatory basis, preventive and primary care services. (Effective May 1, 2010)

Place of Employment- Worksite

A location, not described by any other POS code, owned or operated by a public or private entity where the patient is employed, and where a health professional provides on-going or episodic occupational medical, therapeutic or rehabilitative services to the individual. (This code is available for use effective January 1, 2013 but no later than May 1, 2013)

19 Unassigned N/A

Urgent Care

Location, distinct from a hospital emergency room, an office, or a clinic, whose purpose is to diagnose and treat illness or injury for unscheduled, ambulatory patients seeking immediate medical attention.

Inpatient Hospital

A facility, other than psychiatric, which primarily provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services by, or under, the supervision of physicians to patients admitted for a variety of medical conditions.

Outpatient Hospital

A portion of a hospital which provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization.

23 Emergency

Room – Hospital

A portion of a hospital where emergency diagnosis and treatment of illness or injury is provided.

24 Ambulatory

Surgical Center

A freestanding facility, other than a physician's office, where surgical and diagnostic services are provided on an ambulatory basis.

Birthing Center

A facility, other than a hospital's maternity facilities or a physician's office, which provides a setting for labor, delivery, and immediate post-partum care as well as immediate care of new born infants.

Military Treatment Facility

A medical facility operated by one or more of the Uniformed Services. Military Treatment Facility (MTF) also refers to certain former U.S. Public Health Service (USPHS) facilities now designated as Uniformed Service Treatment Facilities (USTF).

27-30 Unassigned N/A

Skilled Nursing

A facility which primarily provides inpatient skilled nursing care and related services to patients who require medical, nursing, or rehabilitative services but does not provide the level of care or treatment available in a hospital.

Nursing Facility

A facility which primarily provides to residents skilled nursing care and related services for the rehabilitation of injured, disabled, or sick persons, or, on a regular basis, health-related care services above the level of custodial care to other than mentally retarded individuals.

Custodial Care

A facility which provides room, board and other personal assistance services, generally on a long-term basis, and which does not include a medical component.

Hospice

A facility, other than a patient's home, in which palliative and supportive care for terminally ill patients and their families are provided.

35-40 Unassigned N/A

41 Ambulance -

Land

A land vehicle specifically designed, equipped and staffed for lifesaving and transporting the sick or injured.

42 Ambulance – Air or Water

An air or water vehicle specifically designed, equipped and staffed for lifesaving and transporting the sick or injured.

43-48 Unassigned N/A

Independent Clinic

A location, not part of a hospital and not described by any other Place of Service code, that is organized and operated to provide preventive, diagnostic, therapeutic, rehabilitative, or palliative services to outpatients only.

Federally Qualified Health Center

A facility located in a medically underserved area that provides Medicare beneficiaries preventive primary medical care under the general direction of a physician.

Psychiatric Facility

A facility that provides inpatient psychiatric services for the diagnosis and treatment of mental illness on a 24-hour basis, by or under the supervision of a physician.

Psychiatric Facility-Partial Hospitalization

A facility for the diagnosis and treatment of mental illness that provides a planned therapeutic program for patients who do not require full time hospitalization, but who need broader programs than are possible from outpatient visits to a hospital-based or hospital-affiliated facility.

Community Mental Health Center

A facility that provides the following services:

outpatient services, including specialized outpatient services for children, the elderly, individuals who are chronically ill, and residents of the CMHC's mental health services area who have been discharged from inpatient treatment at a mental health facility; 24 hour a day emergency care services; day treatment, other partial hospitalization services, or psychosocial rehabilitation services; screening for patients being considered for admission to State mental health facilities to determine the appropriateness of such admission; and consultation and education services.

Intermediate Care Facility/Mentally Retarded

A facility which primarily provides health-related care and services above the level of custodial care to mentally retarded individuals but does not provide the level of care or treatment available in a hospital or SNF.

Residential Substance Abuse Treatment Facility

A facility which provides treatment for substance (alcohol and drug) abuse to live-in residents who do not require acute medical care. Services include individual and group therapy and counseling, family counseling, laboratory tests, drugs and supplies, psychological testing, and room and board.

Psychiatric Residential Treatment Center

A facility or distinct part of a facility for psychiatric care which provides a total 24-hour therapeutically planned and professionally staffed group living and learning environment.

Non-residential Substance Abuse Treatment Facility

A location which provides treatment for substance (alcohol and drug) abuse on an ambulatory basis.

Services include individual and group therapy and counseling, family counseling, laboratory tests, drugs and supplies, and psychological testing.

58-59 Unassigned N/A

Mass Immunization Center

A location where providers administer pneumococcal pneumonia and influenza virus vaccinations and submit these services as electronic media claims, paper claims, or using the roster billing method. This generally takes place in a mass immunization setting, such as, a public health center, pharmacy, or mall but may include a physician office setting.

Comprehensive

Rehabilitation Facility

A facility that provides comprehensive rehabilitation services under the supervision of a physician to inpatients with physical disabilities.

Services include physical therapy, occupational therapy, speech pathology, social or psychological services, and orthotics and prosthetics services.

Comprehensive Outpatient Rehabilitation Facility

A facility that provides comprehensive rehabilitation services under the supervision of a physician to outpatients with physical disabilities.

Services include…