RFQ-24-087 - Coding-8.20.24.pdf

A. This is a combined synopsis/solicitation for commercial items prepared in accordance with the format in Federal Acquisition Regulation (FAR) Subpart 12.6, as supplemented with additional information included in this notice, FAR Part 12, Acquisition of Commercial Items (Title VIII of the Federal Acquisition Streamlining Act of 1994) (Public Law 103-355). This announcement constitutes the only solicitation; proposals are being requested and a written solicitation will not be issued.

B. The Great Plains Area Indian Health Service (IHS) intends to award a Firm Fixed-Price, Non-Personal Service Type, Commercial Item, Indefinite Delivery/Indefinite Quantity (ID/IQ) Contract in response to Request for Quote (RFQ) RFQ-24-087.

C. This solicitation document and incorporated provisions and clauses are those in effect through Federal Acquisition Circular 2024-05/05/22/2024.

D. This RFQ is a 100% Small Business, Buy-Indian set-aside solicitation and the associated NAICS Code is 541219, which has a small business standard of $25.0.

E. The contract resulting from this solicitation is an ID//IQ Contract. An ID/IQ Contract does NOT obligate any funds. Funds will be obligated prior to starting performance through the issuance of Task Orders. FAR 52.216-18 Ordering, FAR 52.216-19 Ordering Limitations, and FAR 52.216-22 Indefinite Quantity. Orders may be submitted electronically by email.

F. The quoted unit pricing must be “all inclusive” (to include but not be limited to travel, lodging, per diem, fringe benefits, federal, state and local taxes) plus all other costs pertinent to the performance of this contract. Utilize your most competitive and reasonable rates.

Complete the Price Schedule below.

1. Base Year: Date of Award through One Year Medical and Dental Coding, Auditing, and Data Entry Services - 80,000 PCC, totaling $_______________.

2. Option Year One (1): One Year following Base Year Medical and Dental Coding, Auditing, and Data Entry Services - 80,000 PCC, totaling $_______________.

3. Option Year Two (2): One Year following Option Year One Medical and Dental Coding, Auditing, and Data Entry Services - 80,000 PCC, totaling $_______________.

4. Option Year Three (3): One Year following Option Year Two Medical and Dental Coding, Auditing, and Data Entry Services - 80,000 PCC, totaling $_______________.

5. Option Year Four (4): One Year following Option Year Three Medical and Dental Coding, Auditing, and Data Entry Services - 80,000 PCC, totaling $_______________.

Total aggregate amount $____________

G. Medical and Dental Coding, Auditing, and Data Entry Services for the Woodrow Wilson Keeble Memorial Health Care Center (WWKMHCC), Sisseton, South Dakota.

H. See attached Performance Work Statement. Services will be provided for the WWKMHCC, 100 Lake Traverse Drive, Sisseton, South Dakota. The period of performance will be Date of Award through One Year with Four

(4) Option Years.

I. FAR 52.212-1 Instructions to Offerors – Commercial Products and Commercial Services (September

2023).

Quotes shall be submitted on company letterhead stationery, signed, dated and it shall include:

1. Solicitation number RFQ-24-087;

2. Closing Date: September 19, 2024 at 12:00 pm CST;

3. Name, address and telephone number of company and email address of contact person;

4. Technical description of the item/service being offered in sufficient detail to evaluate compliance with the requirements of the solicitation. This may include product literature, or other documents, if necessary;

5. Price and any discount;

6. “Remit to” address, if different than mailing address;

7. A completed copy of the representations and certifications at FAR 52.212-3 (see FAR 52.212-3(b) for those representations and certifications that the offeror shall complete electronically);

8. Acknowledgment of Solicitation Amendments (if any issued);

9. Past performance information, when included as an evaluation factor, to include recent and relevant contracts for the same or similar items and other references (including contract numbers, points of contact with telephone numbers and other relevant information);

10. A statement specifying the extent of agreement with all terms, conditions, and provisions included in the solicitation. Offerors that fail to furnish required representations or information, or reject the terms and conditions of the solicitation may be excluded from consideration.

In addition, Contractors shall provide the following:

• Name and phone number of three (3) current professional references.

• Complete and sign Child Care Position/Personnel Security Office form.

• Complete and sign the Declaration for Federal Employment – Optional Form 306.

• Complete and sign Addendum to Declaration for Federal Employment (OF306).

• Complete and sign Licensure Requirement Form.

• Copy of malpractice insurance coverage.

• Shall meet the Qualifications and Knowledge Requirements in the Performance Work Statement and provide copies of the required documents (if needed).

• Copy of current Board Certification

• Copy of active, current, full and unrestricted license to practice.

• Copy of a recent Health Examination.

• Copy of Diplomas/Specialty Certifications.

• Copies of Continuing Education.

• Current CV/resume.

J. Basis of Award is Lowest Price Technically Acceptable (LPTA). The Government intends to select ONE contractor for award. The proposals will be initially evaluated by lowest price and if the lowest priced proposal submitted is found to be technically acceptable, no other proposals will be evaluated, and award will be made to the lowest priced, technically acceptable offeror. However, if the offeror’s lowest priced proposal is not found technically acceptable, the next offeror’s lowest priced proposal will be evaluated until the lowest priced, technically acceptable proposal is determined. The Government intends to evaluate offers and award without discussions.

The Government reserves the right to ask for clarifications from the lowest-priced offeror being evaluated without approaching other offerors. The Government reserves the right to enter negotiations with the lowest-priced offeror being evaluated without approaching other offerors.

- Contractor will work with the designated schedule.

- Ability to provide personnel who possess computer efficiency and Electronic Health Record experience.

- Ability to provide coding services in a very timely manner for WWKMHCC to bill insurance claims.

- Contractor provides all supporting credential documents as required in the Performance Work Statement.

K. FAR 52.212-3 Offer Representations and Certifications-Commercial Products and Commercial Services (May 2024). See attachment for full text. The Offeror shall complete only paragraph (b) of this provision if the Offeror has completed the annual representations and certification electronically via the System for Award Management (SAM) website accessed through http://www.acquisition.gov. If the Offeror has not completed the annual representations and certifications electronically, the Offeror shall complete only paragraphs (c) through (p) of this provision.

L. FAR 52.212-4 Contract Terms and Conditions-Commercial Products and Commercial Services (November 2023). Applied to this acquisition and it’s incorporated by reference.

M. FAR 52.212-5 Contract Terms and Conditions Required to Implement Statutes or Executive Orders- Commercial Products and Commercial Services (May 2024). See attachment for full text.

N. Attached are the Federal Acquisition Regulations (FAR) & Health & Human Services Acquisition Regulation (HHSAR) clauses that are applicable including below.

O. Submit quote to:

Great Plains Area Indian Health Service Attn: Wenda Wright, Contract Specialist 115 4th Ave. SE, Room 309 Aberdeen, SD 57401 Email: wenda.wright@ihs.gov

Questions in regards to this solicitation shall be submitted in writing by either email no later than August 29, 2024, 10:00am CST.

SECURITY CLEARANCE

A security pre-clearance must be performed for any employees referred to IHS through this contract.

Fingerprints must be completed and adjudicated prior to services being performed under this contract.

No contract award shall be made to any vendor or provider listed on the OIG Exclusion List http://exclusions.oig.hhs.gov throughout the duration of the contract. It shall be the responsibility of the contractor to notify the acquisition official if there is a change in provider.

Performance of this contract will require routine access by employees of the Contractor or its subcontractors to facilities or systems controlled by the Indian Health Service (I.H.S.). Before starting work requiring routine access to I.H.S.

facilities or systems each person must complete a FBI National Criminal History Check (Fingerprint Check) adjudicated by an I.H.S. employee using the Office of Personnel Management Personnel Investigations Processing System.

Contractors shall allow five business days for I.H.S. processing of fingerprints taken electronically at an I.H.S. site and thirty business days for non-electronic processing of fingerprints using FBI Form FD-258. A list of I.H.S. sites with electronic fingerprint capability is available from the Contracting Officer.

In addition, no Contractor or subcontractor employee shall be permitted to perform work under this contract if listed on the HHS Office of Inspector General List of Excluded Individuals/Entities (LEIE), http://exclusions.oig.hhs.gov. As soon as practicable prior to the start of work, the performance of the work the Contractor shall provide to the Contracting Officer the names of all individuals to be used in performance of work for screening against the LEIE. During the performance, the Contractor shall provide the Contracting Officer the names of any additional or substitute employees for screening before they begin work.

The Contractor is responsible for conducting security preclearance investigations in sufficient depth to ensure that each Contractor or subcontractor employee referred to I.H.S. is not on the LEIE and can obtain a favorable fingerprint clearance. Each security preclearance shall be conducted sufficiently in advance of the start of performance to avoid delays caused by denial of access. If this is a Time and Materials, Labor-Hour or Cost Reimbursement contract, the http://www.acquisition.gov/ mailto:wenda.wright@ihs.gov http://exclusions.oig.hhs.gov/ contractor shall not charge for or be reimbursed for labor hours or other costs incurred for employees who are unable to perform due to denial or access or the excess time required to resolve and clear unfavorable security clearance findings. If this is a Fixed Price contract, denial of access due to security clearance findings shall not be a basis for excusable delay or an increase to the contract amount.

Government will pay for the cost to process the contractors suitability clearances. However, multiple investigations for the same position may, at the Contracting Officers discretion, lead to reduction(s) in the contract price of no more than the cost of the extra investigation(s).

Employees that DO NOT have access to LMS, contractors, volunteers, or IHS employees with IPA’s or MOA’s to tribal organizations please, click here IHS Sexual Abuse Prevention website. When the contractors have completed and passed the training, please have them send a copy of the last page of the training with Name, Date, and Time to their Supervisor, COR, and Kimmen LeBeau, e-mail: Kimmen.LeBeau@ihs.gov

No contract award shall be made to any vendor listed on the OIG Exclusions List at http://exclusions.org.hhs.gov throughout the duration of the contract.

Contractor must be registered with the System for Award Management (SAM) at www.sam.gov

ACCEPTANCE PERIOD: Your proposal must stipulate that it is predicated upon all the terms and conditions of this RFQ. In addition, it must contain a statement to the effect that it is firm for a period of at least 30 days from the date of receipt by the Government.

Invoice Processing Platform (IPP)

The Indian Health Service (IHS) has implemented an electronic invoicing system.

In compliance with the Office of Management and Budget (OMB) M-15-19 memorandum “Improving Government Efficiency and Saving Taxpayer Dollars Through Electronic Invoicing” directing Federal agencies to adopt electronic invoicing as the primary means to disburse payment to vendors. Invoices submitted under any award resulting from this solicitation will be required to utilize the Invoice Processing Platform (IPP) in accordance with HHSAR 352.232-71, Electronic Submission and Processing of Payment Requests.

IPP is a secure, web-based electronic invoicing system provided by the U.S. Department of the Treasury’s Bureau of the Fiscal Service, in partnership with the Federal Reserve Bank of St. Louis (FRSTL). Respondents to this solicitation are encouraged to register an account with IPP if they have not already done so. If your organization is already registered to use IPP, you will not be required to re-register- however, we encourage you make sure your organization and designated IPP user accounts are valid and up to date.

The IPP website address is: https://www.ipp.gov

If you require assistance registering or IPP account access, please contact the IPP Helpdesk at (866) 973-3131 (M-F 8AM to 6PM ET), or IPPCustomerSupport@fiscal.treasury.gov

“Should the contractor feel that use of the IPP would be unduly burdensome, their response to this solicitation should include an explanation of this position for a determination by the contracting officer”.

https://www.ihs.gov/sexualabuseprevention/training/ mailto:Kimmen.LeBeau@ihs.gov http://exclusions.org.hhs.gov/ https://obamawhitehouse.archives.gov/sites/default/files/omb/memoranda/2015/m-15-19.pdf https://www.ipp.gov/ mailto:IPPCustomerSupport@fiscal.treasury.gov

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WOODROW WILSON KEEBLE MEMORIAL HEALTH CARE CENTER

INDIAN HEALTH SERVICE

PERFORMANCE WORK STATEMENT

MEDICAL AND DENTAL CODING, AUDITING, AND DATA ENTRY SERVICES

GENERAL:

The Mission of the Sisseton Indian Health Service – Woodrow Wilson Keeble Memorial Health Care Centerr, also known as WWKMHCC, is to provide the best possible healthcare services to the patients on the Lake Traverse Reservation in South Dakota. To meet this mission, the WWKMHCC is requesting an all-inclusive non-personal service contract for Medical and Dental Coding, Auditing, and Data Entry Services.

PURPOSE:

The contractor shall provide medical and dental coding, auditing, and data entry for the WWKMHCC within the Great Plains Area Indian Health Service. The medical and dental coding, auditing, and data entry service will help the WWKMHCC comply with applicable federal and state laws, policies, and regulations.

BACKGROUND:

To ensure proper reimbursement as well as regulatory compliance, the Centers for Medicare and Medicaid Services (CMS) and other federal, state and private payors have initiated precise guidelines for all providers. These guidelines include documentation requirements that demonstrate medical necessity, correct coding, and billing that depends on data integrity. The Office of Inspector General (OIG) of the United States Department of Health and Human Services (DHHS) believes that all participants in the Medicare N Medicaid programs have an ethical and legal duty to ensure the integrity of their transactions with CMS, Federal and State rules, and regulations. To ensure compliance with these directives, the WWKMHCC has initiated a Medical Coding, Dental Coding, Auditing, and Data Entry contract, which shall service as a proactive step in evaluating the WWKMHCC’s exposure to inadequate coding and data entry issues. Services performed by the Contractor will permit the WWKMHCC to move toward strict adherence to SMC, Federal and State compliance guidelines and maintain consistency with the highest standards of business and professional ethics. Coding, dental coding, auditing, and data entry compliance are key components of Medicare’s conditions of participation in fostering and monitoring improved health care outcomes. There may be times when WWKMHCC will need the assistance of the contractor to keep their Outpatient, Dental Coding, Auditing, and Data Entry functions current. As this need arises, the Contractor will be contacted to provide their services.

DESCRIPTION OF SERVICES:

1. Contractor shall perform off-site comprehensive medical coding, dental coding, auditing, and data entry service for the WWKMHCC for Outpatient visits, based on WWKMHCC needs.

Services shall be provided under the highest levels of integrity, compliance, and ethics to obtain the full financial reimbursement to which WWKMHCC is legally entitled for services provided to Indian Health Service (IHS) patients with third party resources. It is the

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Contractor’s responsibility to be knowledgeable of all coding guidelines and to apply these to all patient encounters regardless of third-party resources.

2. The following services shall be required to be provided by the Contractor:

A. Medical Coding: Capture of all appropriate information from the Electronic Health Record (EHR) for health data statistics, reimbursement, and patient care purposes by assigning all proper and necessary International Classification of Diseases (ICD) diagnosis and procedure codes, Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS), Evaluation and Management (E/M) codes and appropriate Modifiers.

B. Data Entry: Enter information from the E.H.R Note into the RPMS PCC Package ensuring that all data items specific to the individual visit are captured

C. To be in compliance with the Indian Health Manual, Part 5-Management Services, Chapter 1-Third-Party Revenue Accounts Management and Internal Controls, 5-1.3 Procedures F. Health Information Management Coding/Data Entry (1) Coding Timelines, all visits must be coded within 4 business days from the date of service.

D. Visits that are marked as Incomplete will continue to be monitored by the Contractor to ensure that the missing information being requested has been provided. The contractor will charge the government only once for the completing the visit.

E. Only those visits that are assigned by the COR will be processed by the contractor.

F. There may be times when there is more than one “item” displaying in the Coding Queue that belongs to a “visit”. The contractor will only charge for the visit, not each item. For example, an “item” may be ancillary services that belong to the “visit” but display separately in the Coding Queue. These “items” will all need to be merged to the “visit” and counted as one “visit”.

G. Auditing of coding services may be requested by WWKMHCC. If requested, coding quality audits will be completed on a quarterly basis. Ten percent of the charts coded in the quarter will be reviewed to determine accurate code assignments including ICD-10, CPT, HCPCs and E & M codes. Findings from the reviews will be utilized to improve coding and meeting Office of Resource Access and Partnerships (ORAP) requirements for an outside coding auditor McManus & Monsalve.

H. WWKMHCC requires that services provided upon request continue without interruption during the term of this contract.

I. The Contractor shall furnish all necessary personnel, facilities, supplies, equipment, and such other professional competence normally furnished to provide Coding and Data

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Entry services for the WWKMHCC. Services shall be performed off-site at the Contractor’s location. All stated volumes and quantities are estimates.

PERIOD OF PERFORMANCE:

Date of Award, Base Year plus four (4) Option Years.

QUALIFICATIONS:

A. Contractor must have experience Electronic Health Record (EHR).

B. The contractor shall utilize qualified, experienced, and credentialed professional staff to perform medical coding and data entry services accurately and proficiently, and to adhere to applicable federal and state laws, regulations, and policies.

a. Credentialed staff shall be certified by the American Academy of Professional Coders

(AAPC) or the American Health Information Management Association (AHIMA).

b. Contractor shall require non-credentialed staff that is in training for certification by

AAPC or AHIMA, to be supervised by a coder that is certified by at least one of these organizations.

c. Contractor is to identify the minimum number of encounters their staff is responsible for completing daily. (Provide your expected daily quota for one individual or per specialty for both Outpatient and Inpatient Coding)

C. While adhering to the Indian Health Service Privacy Act and Health Insurance Portability and Accountability Act (HIPPA) policies and regulations, the contractor shall access the IHS RPMS PCC data entry and EHR packages. Access shall be through Virtual Private Network (VPN) connections through the Office of Information Technology (OIT) in Albuquerque, New Mexico.

REPORTING REQUIREMENTS:

1) The Government and Contractor shall develop and maintain a data tracking log and process to ensure that all coding queue visits are accounted for and processed.

a) The exact format of the Contractor’s tracking log will be determined in consultation with the

Government COR after the contract is awarded.

2) The Contractor shall maintain a database and provide monthly volume and status reports to the

COR. Reports shall include the number of visits received that month, which includes the number of visits that were marked as reviewed/complete and incomplete. For those visits that were marked incomplete, the quantity and reason will be indicted.

3) The monthly volume and status reports shall be submitted with the Contractor’s monthly invoice as provided for the invoicing provisions of this contract.

a) The exact format of the database will be determined in consultation with the Government

COR after the contract is awarded.

TECHNICAL REQUIREMENTS:

1. Ability to provide personnel who possess computer efficiency and Electronic Health Record experience.

2. Ability to provide coding services in a very timely manner for WWKMHCC to bill insurance claims.

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QUALITY CONTROL:

A. The Contractor’s quality control program shall integrate quality auditing, measurement method validation, and sample validation into the measurement process. The Contractor shall outline how the quality control plan will be used to help deliver the highest possible quality results within committed resources, an also identify how often Quality Analysis (QA) will be performed, the percentage of sampling that is done, the acceptable error rate for Contractor staff.

B. Quality Control shall also include the Contractor’s turnaround time from the date the visit is received at the Contractor’s location to the date it is marked as Reviewed/Completed.

Surveillance will be achieved through the Contractor’s volume/status reports.

COMMUNICATIONS:

The contractor shall provide a point of contact who shall be responsible for the performance of the work, and shall have full authority to act for the contractor on all matters relating to the daily operation of this contract. The contractor shall designate this individual, in writing, to the Contracting Officer before the contract start date. An alternate may be designated but the contractor shall identify those times when the alternate shall be the primary point of contact.

The contractor and personnel shall maintain open and professional communication with members of the HIM (Health Information Management) department. Complaints validated by the Performance Improvement Coordinator and HIM Supervisor shall be reported in writing to the COR for action.

When the HIM Supervisor is absent, the contractor and personnel shall follow the delegation of authority and perform duties as assigned by the HIM Supervisor’s designee.

PRIVACY ACT INFORMATION AND BUSINESS ASSOCIATE AGREEMENT CLAUSE:

Contractor staff will have access to sensitive information covered under the Privacy Act and HIPAA. The Contractor shall prevent the unauthorized release of information obtained by staff during the performance of work required by this contract. The Contractor shall ensure that employees are aware of and receive as necessary training on all regulations and laws such as the Privacy Act and HIPAA that restricts the release of information. The Contractor shall be required to comply with the Business Associate Agreement Clause and Business Associate Agreement included in this contract. All medical record information generated in the performance of this contract will remain the property of, and subject to the exclusive control of. the Indian Health Service.

SUBMISSION OF WORKLOAD INFORMATION AND INVOICES:

The contractor shall establish an invoicing process that details a breakdown of monthly services provided during the given month per the contract requirements. The invoice shall include a grand total for the amount due the contractor for all services provided. A proper invoice shall be in the format as specified in FAR 52.212-4 (g) Payment Documentation and Process. Invoices shall be issued as soon as possible after the last business day of the month, but not later than the 10th of each month. It is imperative that invoicing timeframes be adhered to in order to prevent late or missed payments.

Payment shall be made upon receipt of a proper invoice, Contractor’s monthly status report (see the Reporting Requirements of this contract) and satisfactory contract performance.

CONTRACT OFFICER’S REPRESENTATIVE DESIGNATION:

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The Contracting Officer’s Representative (COR) representing the Government for the purpose of this contract shall be designated in writing by the Contracting Officer at the Great Plains Area Indian Health Service.

The COR is responsible for:

1. Monitoring the Contractor’s technical progress, including the surveillance and assessment of performance and recommending to the Contracting Officer, changes in requirements;

2. Interpreting scope of work;

3. Performing technical evaluations required;

4. Performing technical inspections and acceptances required by this contract;

5. Monitoring funds for obligation under this contract

6. Assisting the Contractor in the resolution of technical problems encountered during performance of this contract.

In no event is the COR empowered to change any of the terms and conditions of the contract. Changes in the scope of work, contract price, quantity, and quality or delivery schedule shall be made only by the Contracting Officer by properly executed modification to the contract. The designation of a COR does not authorize or provide a legal right to change any kind of contractual terms regardless of the Contractor’s apparent difficulties in fulfilling contact requirements.

The designated COR for this contract is:

Ella Mae Greybuffalo, Level II COR Administrative Support Assistant Woodrow W. Keeble Memorial Health Care Center 100 Lake Traverse Drive Sisseton, SD 57262 Phone: (605)742-3862 Fax: (605)742-3896 Email: Ella.Greybuffalo@ihs.gov

TASK ORDERS:

TASK ORDER AGREEMENTS. This contract type allows the service unit program offices to place an order with the Contractor on an as needed basis. In accordance with the Federal Acquisition Regulation (FAR) 52.216-18, Ordering (OCT 1995), IHS will obligate the funding and order the services by issuing a task order through the Agency's automated procurement systems, iProcurement and PRISM.

The contract provisions authorize the program offices at WWKMHCC to issue the task orders, within their procurement authority, for the commercial item contract for the services needed during the contract term. Each task order will reference the contract number and contain a task order number assigned by the automated procurement systems.

TASK ORDER PROCEDURES. The Contractor shall initiate work when directed by a task order issued by the Contracting Officer. No work under any task order shall be performed unless specifically authorized by the Contracting Officer. Approval of a task order shall not constitute approval to exceed any item mailto:Ella.Greybuffalo@ihs.gov

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ISSUANCE OF TASK ORDERS. Task orders shall be issued on a fixed price basis and shall describe the specific work to be performed and the total cost. Each task order shall make reference to the proper funding document (requisition).

The estimated hours for performance of each task shall be set forth in each task order. Each task order shall not exceed the hour's specified and total amount obligated for each task order. The total amount of all task orders shall not exceed the maximum amount negotiated for the contract period.

The Contractor shall not proceed with performance under any task order until such time approval is granted by the Contracting Officer.

COMPLETION OF TASK ORDERS. Upon completion of each task order, the contractor shall submit invoice as outlined in the payment process.

HOMELAND SECURITY PRESIDENTIAL DIRECTIVE-12 (HSPD-12):

The Homeland Security Presidential Directive 12 (HSPD-12) is the directive that was issued for the “Policy for a Common Identification Standard for Federal Employees and Contractors”. HSPD-12 calls for all federal employees and contractors to use a standard smart credential to verify their identity for secure access to federal buildings and information systems. HSPD-12 called upon the National Institute of Standards and Technology (NIST) to develop the actual technical standard, and the Office of Management and Budget (OMB) to manage implementation of the credentials. The uses of the credentials are left to the agencies themselves to decide. The purpose of HSPD-12 is to provide a common reliable identification verification for government employees and contractors. It will help to protect against a variety of threats including:

• Unauthorized access to physical facilities or logical assets

• Improper issuance of valid credential to malicious holder

• Counterfeiting of credentials

• Intercept or probing to access stored information

• Successful cryptanalytic attacks against stored protected information

• Use of stolen or borrowed credential to gain access to physical or logical systems

• Intercept/technical surveillance to capture PIN(s)

• Use of credential issued for access to lower sensitivity/criticality assets to achieve access to more sensitive/critical assets

In compliance with HSPD-12, the Health and Human Services, Indian Health Service (IHS), Woodrow Wilson Keeble Memorial Health Care Center, establishes the requirement to evaluate and investigate all federal employees and contractor employees prior to issuing a Personal Identification Verification (PIV) card. Thus, all persons privileged to be employed in the Federal Government shall be reliable, trustworthy, of good conduct and character, and of complete and unwavering loyalty to the United

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States. The HSPD-12 link below covers the federal law requiring PIV cards for federal network access. A PIV card id required after the 120 day-waiver period, with no exceptions. Homeland Security Presidential Directive 12: Policy for a Common Identification Standard for Federal Employees and Contractors https://www.dhs.gov/homeland-security-preseidential-directive-12 . It is a mandatory requirement that all IHS information system users must take annual security training in order to fulfill Federal mandates and regulations. In addition, all new users must successfully complete this course within 24 hours of on-boarding. Failure to complete training requirements will result in the loss of information systems access.

PAYMENT PROCESS:

The Contractor shall submit a monthly invoice for services rendered into the iPP electronic invoicing system. Each invoice shall include the following:

1. Contractor/Vendor Name

2. Mailing Address

3. Telephone Number

4. Tax Identification Number (TIN)

5. Invoice Date and Number

6. Purchase Order Number and Task Order (in Block #3 of the OF-347 form)

7. UEI Number (Unique Entity Identification)

8. Description of services provided, quantity, unit of issue, unit price, and total amount due https://www.dhs.gov/homeland-security-preseidential-directive-12

To:

Subject:

New Hire and Supervisor of position covered by Public Law 101-630

Provisional Authorization- pending favorably adjudicated background investigation

This serves as not ice to the supervisor and new hire/contractor/volunteer/affiliate that they will be performing work and/or occupying a position that is covered by Public Laws (P.L.) 101-630, Indian Child Protection and Family Violence Prevention Act and 101-647, Crime Control Act. An individual employed/working or being considered for employment (Federal, contractor, volunteer, or affiliate) at the Indian Health Service with duties and responsibilities involving regular contact with or control over Indian children must undergo a background investigation. Prior to the receipt of a favorably adjudicated background investigation, the individual will have provisional status. At all times whenever Indian children are in the care, custody, and/or control of an individual in a provisional status, the individual is required to be under the supervision and in sight of a staff person who has a favorably adjudicated background investigation that includes child care coverage.

The following individual has been granted provisional authorization for the identified position, which has been designated as a position covered by P.L. 101-630:

Name: _________________________________ Position title: ____________________________

The following conditions must be met for the individual:

Pre-employment suitability has been favorably adjudicated prior to entrance on duty.

Continued processing of background investigation – Tier 1 with child care (minimum).

Provide requested documentation/information as requested from the Personnel Security/HR Office.

Supervisor must ensure that new hires/contractors/affiliates who are in a provisional status and have Indian children in their care, custody, and/or control, are within the sight and supervision of a staff person who has a favorably adjudicated background investigation that includes child care coverage.

Supervisors are required to sign indicating your acceptance, responsibility, and compliance with the above criteria, and will ensure that the above named individual is assigned to appropriate personnel whenever Indian children are in their care, custody, and/or control. Failure to comply with the above criteria can result in disciplinary action, up to and including removal.

Department Supervisor/Designee Date

The facility/service unit is required to work with the Area Personnel Security/HR Office designee to maintain a list of staff members who have a favorably adjudicated background investigation with child care coverage on file for supervisors to identify and assign personnel to provide coverage to individuals in a provisional status.

I have verified that I have worked with the facility/service unit to ensure that a list of favorably adjudicated staff members is available for the supervisor’s use.

Personnel Security Representative/HR Designee Date

This provisional authorization is in effect until the favorably adjudicated certification of investigation is in place. I am aware that failure to comply with the above criteria could result in disciplinary action, up to and including removal/termination.

Employee/Contractor/Affiliate Date

1 / 2018

Indian Health Service Office of Human Resources

Declaration for Federal Employment* (*This form may also be used to assess fitness for federal contract employment)

Form Approved:

OMB No. 3206-0182

U.S. Office of Personnel Management

5 U.S.C. 1302, 3301, 3304, 3328 & 8716

Optional Form 306 Revised October 2019

Previous editions obsolete and unusable

Instructions The information collected on this form is used to determine your acceptability for Federal and Federal contract employment and your enrollment status in the Government's Life Insurance program. You may be asked to complete this form at any time during the hiring process. Follow instructions that the agency provides. If you are selected, before you are appointed you will be asked to update your responses on this form and on other materials submitted during the application process and then to recertify that your answers are true.

All your answers must be truthful and complete. A false statement on any part of this declaration or attached forms or sheets may be grounds for not hiring you, or for firing you after you begin work. Also, you may be punished by a fine or imprisonment (U.S. Code, title 18, section 1001).

Either type your responses on this form or print clearly in dark ink. If you need additional space, attach letter-size sheets (8.5" X 11").

Include your name, Social Security Number, and item number on each sheet. We recommend that you keep a photocopy of your completed form for your records.

Privacy Act Statement The Office of Personnel Management is authorized to request this information under sections 1302, 3301, 3304, 3328, and 8716 of title 5, U. S. Code. Section 1104 of title 5 allows the Office of Personnel Management to delegate personnel management functions to other Federal agencies. If necessary, and usually in conjunction with another form or forms, this form may be used in conducting an investigation to determine your suitability or your ability to hold a security clearance, and it may be disclosed to authorized officials making similar, subsequent determinations.

Your Social Security Number (SSN) is needed to keep our records accurate, because other people may have the same name and birth date. Public Law 104-134 (April 26, 1996) asks Federal agencies to use this number to help identify individuals in agency records. Giving us your SSN or any other information is voluntary. However, if you do not give us your SSN or any other information requested, we cannot process your application. Incomplete addresses and ZIP Codes may also slow processing.

ROUTINE USES: Any disclosure of this record or information in this record is in accordance with routine uses found in System Notice OPM/GOVT-1, General Personnel Records. This system allows disclosure of information to: training facilities; organizations deciding claims for retirement, insurance, unemployment, or health benefits; officials in litigation or administrative proceedings where the Government is a party; law enforcement agencies concerning a violation of law or regulation; Federal agencies for statistical reports and studies; officials of labor organizations recognized by law in connection with representation of employees; Federal agencies or other sources requesting information for Federal agencies in connection with hiring or retaining, security clearance, security or suitability investigations, classifying jobs, contracting, or issuing licenses, grants, or other benefits; public and private organizations, including news media, which grant or publicize employee recognitions and awards; the Merit Systems Protection Board, the Office of Special Counsel, the Equal Employment Opportunity Commission, the Federal Labor Relations Authority, the National Archives and Records Administration, and Congressional offices in connection with their official functions; prospective non-Federal employers concerning tenure of employment, civil service status, length of service, and the date and nature of action for separation as shown on the SF 50 (or authorized exception) of a specifically identified individual; requesting organizations or individuals concerning the home address and other relevant information on those who might have contracted an illness or been exposed to a health hazard; authorized Federal and non-Federal agencies for use in computer matching; spouses or dependent children asking whether the employee has changed from a self-and-family to a self-only health benefits enrollment; individuals working on a contract, service, grant, cooperative agreement, or job for the Federal government; non-agency members of an agency's performance or other panel; and agency-appointed representatives of employees concerning information issued to the employees about fitness-for-duty or agency-filed disability retirement procedures.

Public Burden Statement Public burden reporting for this collection of information is estimated to vary from 5 to 30 minutes with an average of 15 minutes per response, including time for reviewing instructions, searching existing data sources, gathering the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of the collection of information, including suggestions for reducing this burden, to the U.S. Office of Personnel Management, Reports and Forms Manager (3206-0182), Washington, DC 20415-7900. The OMB number, 3206-0182, is valid. OPM may not collect this information, and you are not required to respond, unless this number is displayed.

Form Approved:

OMB No. 3206-0182

U.S. Office of Personnel Management

5 U.S.C. 1302, 3301, 3304, 3328 & 8716

Optional Form 306 Revised October 2019

Previous editions obsolete and unusable

General Information

1. FULL NAME (Provide your full name. If you have only initials in your name, provide them and indicate "Initial only". If you do not have a middle name, indicate "No Middle Name". If you are a "Jr.," "Sr.," etc. enter this under Suffix. First, Middle, Last, Suffix)

2. SOCIAL SECURITY NUMBER

3a. PLACE OF BIRTH (Include city and state or country)

3b. ARE YOU A U.S. CITIZEN?

YES NO (If "NO", provide country of citizenship) ♦

4. DATE OF BIRTH (MM / DD / YYYY)

5. OTHER NAMES EVER USED (For example, maiden name, nickname, etc.)

6. PHONE NUMBERS (Include area codes)

Day ♦ Night ♦

Selective Service Registration If you are a male born after December 31, 1959, and are at least 18 years of age, civil service employment law (5 U.S.C. 3328) requires that you must register with the Selective Service System, unless you meet certain exemptions.

7a. Were you born a male after December 31, 1959? YES NO (If "NO", proceed to 8.)

7b. Have you registered with the Selective Service System? YES (If "YES", proceed to 8.) NO (If "NO", proceed to 7c.)

7c. If "NO," describe your reason(s) in item 16.

Military Service

8. Have you ever served in the United States military? YES (If "YES", provide information below) NO

If your only active duty was training in the Reserves or National Guard, answer "NO.”

If you answered "YES," list the branch, dates, and type of discharge for all active duty.

Branch From (MM/DD/YYYY) To (MM/DD/YYYY) Type of Discharge

Background Information For all questions, provide all additional requested information under item 16 or on attached sheets. The circumstances of each event you list will be considered. However, in most cases you can still be considered for Federal jobs.

For questions 9,10, and 11, your answers should include convictions resulting from a plea of nolo contendere (no contest), but omit (1) traffic fines of $300 or less, (2) any violation of law committed before your 16th birthday, (3) any violation of law committed before your 18th birthday if finally decided in juvenile court or under a Youth Offender law, (4) any conviction set aside under the Federal Youth Corrections Act or similar state law, and (5) any conviction for which the record was expunged under Federal or state law .

9. During the last 7 years, have you been convicted, been imprisoned, been on probation, or been on parole?

(Includes felonies, firearms or explosives violations, misdemeanors, and all other offenses.) If "YES," use item 16 to provide the date, explanation of the violation, place of occurrence, and the name and address of the police department or court involved.

10. Have you been convicted by a military court-martial in the past 7 years? (If no military service, answer "NO.") If "YES," use item 16 to provide the date, explanation of the violation, place of occurrence, and the name and address of the military authority or court involved.

11. Are you currently under charges for any violation of law? If "YES," use item 16 to provide the date, explanation of the charges, place of occurrence, and the name and address of the police department or court involved.

12. During the last 5 years, have you been fired from any job for any reason, did you quit after being told that you would be fired, did you leave any job by mutual agreement because of specific problems, or were you debarred from Federal employment by the Office of Personnel Management or any other Federal agency? If "YES," use item 16 to provide the date, an explanation of the problem, reason for leaving, and the employer's name and address.

13. Are you delinquent on any Federal debt? (Includes delinquencies arising from Federal taxes, loans, overpayment of benefits, and other debts to the U.S. Government, plus defaults of Federally guaranteed or insured loans such as student and home mortgage loans.) If "YES," use item 16 to provide the type, length, and amount of the delinquency or default, and steps that you are taking to correct the error or repay the debt.

YES NO

YES NO

YES NO

YES NO

YES NO

Form Approved:

OMB No. 3206-0182

U.S. Office of Personnel Management

5 U.S.C. 1302, 3301, 3304, 3328 & 8716

Optional Form 306 Revised October 2019

Previous editions obsolete and unusable

Additional Questions

14. Do any of your relatives work for the agency or government organization to which you are submitting this form?

(Include: father, mother, husband, wife, son, daughter, brother, sister, uncle, aunt, first cousin, nephew, niece, father-in-law, mother-in-law, son-in-law, daughter-in-law, brother-in-law, sister-in-law, stepfather, stepmother, stepson, stepdaughter, stepbrother, stepsister, half-brother, and half-sister.) If "YES," use item 16 to provide the relative's name, relationship, and the department, agency, or branch of the Armed Forces for which your relative works.

15. Do you receive, or have you ever applied for, retirement pay, pension, or other retired pay based on military, Federal civilian, or District of Columbia Government service?

Continuation Space / Agency Optional Questions

YES NO

YES NO

16. Provide details requested in items 7 through 15 and 18c in the space below or on attached sheets. Be sure to identify attached sheets with your name, Social Security Number, and item number, and to include ZIP Codes in all addresses. If any questions are printed below, please answer as instructed (these questions are specific to your position and your agency is authorized to ask them).

Certifications / Additional Questions APPLICANT: If you are applying for a position and received a tentative/conditional job offer or have not yet been selected, carefully review your answers on this form and any attached sheets.

APPOINTEE: If you are being appointed, carefully review your answers on this form and any attached sheets, including any other application materials that your agency has attached to this form. If any information requires correction to be accurate as of the date you are signing, make changes on this form or the attachments and/or provide updated information on additional sheets, initialing and dating all changes and additions.

When this form and all attached materials are accurate, read item 17, complete 17b, read 18, and answer 18a, 18b, and 18c as appropriate.

17. I certify that, to the best of my knowledge and belief, all of the information on and attached to this Declaration for Federal Employment, including any attached application materials, is true, correct, complete, and made in good faith. I understand that a false or fraudulent answer to any question or item on any part of this declaration or its attachments may be grounds for not hiring me, or for firing me after I begin work, and may be punishable by fine or imprisonment. I understand that any information I give may be investigated for purposes of determining eligibility for Federal employment as allowed by law or Presidential order. I consent to the release of information about my ability and fitness for Federal employment by employers, schools, law enforcement agencies, and other individuals and organizations to investigators, personnel specialists, and other authorized employees or representatives of the Federal Government. I understand that for financial or lending institutions, medical institutions, hospitals, health care professionals, and some other sources of information, a separate specific release may be needed, and I may be contacted for such a release at a later date.

17a. Applicant's Signature: Date:

(MM / DD / YYYY)

17b. Appointee's Signature: Date:

(MM / DD / YYYY)

18. Appointee (Only respond if you have been employed by the Federal Government before): Your elections of life insurance during previous Federal employment may affect your eligibility for life insurance during your new appointment. These questions are asked to help your personnel office make a correct determination.

18a. When did you leave your last Federal job? Date:

(MM / DD / YYYY)

18b. When you worked for the Federal Government the last time, did you waive Basic Life Insurance or any type of optional life insurance?

18c. If you answered "YES" to item 18b, did you later cancel the waiver(s)? If your answer to item 18c is "NO," use item 16 to identify the type(s) of insurance for which waivers were not canceled.

YES NO DO NOT KNOW

YES NO DO NOT KNOW

Appointing Officer:

Enter Date of Appointment or Conversion

MM / DD / YYYY

OMB Approved Form No. 0917-0028 Expiration Date: 04/30/2025

Addendum to Declaration for Federal Employment (OF 306) Indian Health Service

Child Care & Indian Child Care Worker Positions Item 16. Agency Specific Questions

Name: ___________________________ Social Security Number: __________________ (Please print)

Job Title in…