RFQ-CSU-23-001-JJP SOW.pdf

Statement of Work (SOW)

PROJECT TITLE: Clearinghouse and Eligibility Verification Services

BACKGROUND/PURPOSE:

The Crow Service Unit (CSU) and two (2) satellite clinics is seeking a well-established Medical Claims Clearinghouse service provider whose proposed solution is the most advantageous in meeting the requirements of all three (3) sites. CSU requires a software application that provides a secure exchange of electronic payer eligibility information in a system that automates patient eligibility inquiries for CSU . Additionally, CSU requires an application that will provide daily Medicare AR reports for better account management, all in compliance with HIPAA and Indian Health Service (IHS) Office of Information Technology (OIT) mandates.

The CSU process up to 72,000 claims per year, approximately 6,000 per monthly billing cycle. Services provided serves as a means of enhancing and maximizing third party revenue and collection activities. The medical claims clearinghouse will work directly with CSU to securely and electronically transmit medical claims to insurance companies and to electronically verify patient eligibility.

The proposed solution will have the ability to be integrated into the existing health information system (RPMS) billing software and automatically in processing exported claims to third party payers; Medicare, Veterans Affairs, and Private Insurance electronic claims, currently billing is completed by CSU Staff. The CSU is also seeking a solution that is able to setup third party payer accounts with minimal transition from the existing service provider. The proposed solution should be able to review and filter claims against established edits to identify any errors. As well as provide a means to correct the claim before the claim is submitted to the insurance company.

SCOPE: The Contractor shall provide Clearinghouse and Eligibility Verification Software as a service for eligibility verification and medical claims processing at the CSU. All eligibility verifications will be provided in a secure, private, and electronic format with multi user access on for all three (3) sites.

APPLICABLE DOCUMENTS: Health Insurance Portability and Accountability Act, Privacy Act of 1974.

SPECIFIC TASKS:

A. OBJECTIVES:

The CSU seeks to utilize a Medical Claims Clearinghouse Service that can process medical claims and enhance existing procedures and processes. The CSU is interested in service types that will help improve the efficiency of insurance claim processing. The selected Vendor must demonstrate a stable, compliant, and comprehensive solution that will interface with existing technologies and processes with minimal service disruption.

The selected Vendor must demonstrate broad knowledge and experience in providing information services to federal health facilities similar to CSU.

B. REQUIREMENTS:

i. Platform Interface: Proposed solution should include an intuitive interface capable of immediate deployment and operation by the CSU personnel. Proposed solution will interface with our existing health information system (RPMS) and automatically post response data into existing data fields and system records.

ii. The proposed solution must have an estimated timeline of when services will be fully functional for use.

iii. The proposed solution(s) must have the following service types:

1. CLEARINGHOUSE

a. Shall have the ability to import through RPMS export 6,000 claims per monthly billing cycle

b. summary of the number of claims exported by day successful to reconcile with RPMS exports.

c. shall have electronic claims submission and Electronic Remittances

Advice (ERA) – Automatically updates Payments & Adjustments.

Capability for CSU to download electronic EDI files and interface for posting to RPMS. 837 ERA Claims are currently in use. Industry Standard ERA’s must be available.

d. Claim Status Reports – Dashboard reports on claims; ie., top 10 payers, amounts, number of claims within time frames. The vendor must have an accurate status of our claims upon request.

e. Denial Prevention and Rejection Analysis – A process and report that identifies claims rejecting in the export process. Ability to correct those claims prior to export. Technical assistance is provided same day and no later than 24 hours. Reductions in rejections and explanation of error codes.

g. Direct Data Entry – Edit and correct claims on line.

h. Printed Claims & EOB’s– Automatically drop claims (Pharmacy Claims to 837I, Dental Claims to ADA-837D, Professional to 837P) to paper and submit to Vendor when requested by Service Unit. Ability to print EOB’s for all claims processed.

i. Secondary Claims Processing – Electronic Submission.

j. Real-Time Support – Technical System support and personal training by an experienced consultant upon selection for staff.

k. Set-up Of Third Party Payers – Sets up of accounts for export and import of ERA’s in Clearinghouse. The transition of migration with no down time in claim processing after selection of Clearinghouse

l. Transaction Summary – All the Clearinghouse activities must be available upon request.

2. ELIGIBILITY VERIFICATION

a. Eligibility – Real time eligibility checks.

b. Third Party – Identifies and scrubs claims by Third Party edits/criteria.

3. PROFESSIONAL SERVICES

a. Training – Online training to all system users and administrators.

b. Onboarding – Payers and Providers

c. Maintenance and Support:

I. Technical Support: The proposed solution should offer robust customer support that will be responsive to the needs of the CSU and provide timely resolution to clearinghouse system outages.

The CSU is interested in a Vendor offering a high degree of accountability and ownership of technical support processes that will assist in meeting critical deadlines for claim submission and fulfillment.

II. The contractor shall provide routine support to implement corrections to service occurring as a result of errors, flaws or other failures within their service.

III. The contractor shall notify a designated CSU point of contact or the Technical Representative of any scheduled maintenance that shall result in downtime.

IV. Notification at least (2) days prior to the maintenance period.

V. The contractor shall notify a designated CSU point of contact of any issues at the CSU that result in a disruption of data exchange capabilities. This notification shall occur as soon as the disruption is identified.

VI. The contractor shall provide customer service support for reporting, documenting, tracking and resolving of service problems, which shall be available via telephone and email to CSU technical staff.

iv. Compliance: The proposed solution(s) shall comply with all aspects of Joint

Commission (JCAHO); Health Insurance Portability and Accountability Act of 1996 (HIPAA). All facets of the proposed services should adhere to the laws that regulate the processing and storage of protected health information with sufficient security features to maintain the integrity, privacy and security of patient and billing data.

v. User Access: Up to Twenty five (25) CSU staff will have simultaneous access to the provided solution.

1. PLACE OF PERFORMANCE:

Each location requires its own NPI Number.

a. Crow Service Unit b. Pryor Health Clinic c. Lodge Grass Clinic

1 Hospital Way Pryor Gap Road 418 Harding Ave Crow Agency, MT 59022 Pryor, MT 59066 Lodge Grass, MT 59050

2. DELIVERABLES:

The will provide point-of-service eligibility data from third party insurance databases.

These inquiries and responses will provide accurate and up-to-date eligibility information available to the end user. The vendor will also provide Medicare AR dashboard and reports for AR management.

GOVERNMENT-FURNISHED EQUIPMENT AND INFORMATION: The Contractor is responsible for providing all equipment, labor, transport, and materials to complete the Work.

PLACE OF PERFORMANCE:

Each location requires its own NPI Number.

a. Crow Service Unit b. Pryor Health Clinic c. Lodge Grass Clinic 1 Hospital Way East Main Street 418 Harding Ave

PERIOD OF PERFORMANCE:

Performance of this contract is intended to start February 1, 2023, through January 31, 2024 with four (4) 12-month option years. If the Government exercises the options pursuant to Federal Acquisition Regulation (FAR) 52.217-9, Option to Extend the Term of the Contract (MAR 2000), the period of performance shall be extended in accordance with the following schedule:

Base Year 02/01/2023 to 01/31/2024 Option Year 1 02/01/2024 to 01/31/2025 Option Year 2 02/01/2025 to 01/31/2026 Option Year 3 02/01/2026 to 01/31/2027 Option Year 4 02/01/2027 to 01/31/2028

1. SECURITY: N/A