Attachment_I_-_Statement_of_Work.pdf

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 and ensuring the

Bureau of Prisons (BOP) complies with the requirements of the

Prompt Payment Act and Statements of Federal Financial

Accounting Standards (SFFAS).

Background

The BOP currently provides healthcare to more than 219,000 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 BOP system. There are no accumulators or capitation in the BOP 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, BOP policies/procedures, the Joint Commission on

Accreditation of Healthcare Organization (JCAHO), and American

Corrections Association (ACA) standards. Primary care is provided by BOP staff physicians and mid-level practitioners.

In addition, each institution within the BOP 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) Operation Federal Medicare rates for the applicable area for inpatient facility services; 2)

Medicare fee schedule amounts for the area for outpatient facility services; and 3) 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 BOP. The BOP has been successful in awarding a majority of comprehensive medical contracts based on these structured Medicare rates. However, there are locations where the BOP has been unsuccessful in awarding contracts based on Medicare rates. In those cases, contracts are typically awarded at a percentage off billed charges or fee schedule. 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 BOP contracts and agreements. These contracts and agreements will each have formally negotiated and specifically, documented contract payment rates.

The BOP is the sole payer for all healthcare services rendered to BOP 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, by 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 (see attachment A), 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).

Requirements

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.

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

The contractor shall also incorporate internal and systemic controls in the adjudications process to preclude duplicate payments and ensure that the BOP 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.

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. A preauthorization process shall also be incorporated into the system (see number 3 below.)

Preauthorization

The contractor shall describe how they will integrate a preauthorization process into their claims adjudication system to include a .pdf of the form. The contractor shall include specific details on how preauthorization 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 preauthorization will not be given. Each episode of care for contracted specialty physician, outpatient, and inpatient hospital services shall be preauthorized by the institutions. All Medicare-based services provided on-site at a

BOP facility are to be preauthorized.

A. The BOP shall provide the following data elements commonly found on the UB04 upon initiation of preauthorization process:

1. 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.

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

3. Inmate first and last name.

4. Patient’s relationship to insured shall always be self.

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

6. Inmate’s date of birth.

7. Expected date(s) of service.

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

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

10. 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 preauthorization information, the contractor shall provide, within three (3) business days of receiving a preauthorization, a good faith estimate

(GFE)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 BOP within 24 hours. The contractor shall continually refine their cost estimation process to provide increasing accuracy of estimates.

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 BOP. The

POC shall contact the COR when required and shall coordinate any training and site visits to the institutions.

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). 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-9-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 BOP. BOP comprehensive medical contractors should be utilizing their contracted networks;

therefore, the instances of CBC pricing should be minimal.

Contractor shall describe how this type of claim will be adjudicated.

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 BOP with a copy (can be electronic) of the original claim and an explanation of benefits (EOB) for the BOP 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.

Healthcare Provider Invoicing of Medical Services

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

Prompt Payment Considerations

Upon receipt of an invoice (claim) from a healthcare provider, the contractor shall date stamp the claim as received to begin the prompt payment period. 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 BOP institution making payment, a written EOB, within four (4) working days.

Technical and Interoperability Requirements

The proposed system must meet the following technical requirements. A product that meets these requirements will permit the BOP 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 documents between the contractor and the Department of

Justice’s myFX system. Support secure automated file transfers of inmate information from the Bureau’s mainframe system.

C. Allow BOP 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 BOP’s standard is

Microsoft Internet Explorer 8.0.

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

Explorer. Current BOP 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 BOP information systems such as the email system GroupWise, network file server system from Novell, and our electronic medical and pharmacy systems.

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

Security Requirements

The proposed system must meet the following security requirement:

A. Provided security safeguards that are consistent with

HIPAA.

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

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

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

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

Data

The contractor shall describe how the BOP 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 BOP owns all data generated by the medical claims adjudication process and the BOP 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 BOP data systems. The contractor shall also provide technical documentation regarding all data files and formats, as well as provide updated documentation as changes occur.

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 2640.2E and the Federal Bureau of Prison’s Human Resource Management Manuel 3000.02D 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:

1. Critical Sensitive.

2. Non-Critical Sensitive.

3. MT-Related Services – NON sensitive Data Access.

Each contractor employee with access to BOP-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 BOP may permit other Government security clearances to be substituted for the above background investigation, if determined by the BOP to be equal, current, and provided the contractor submits adequate documentation to support the BOP’s determination.

In addition to the aforementioned background investigations, the BOP 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 BOP 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.

A. DOJ Order 2640.2E – 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.

B. 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.

C. 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.

D. 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 BOP program statement, Information Security, P1237.13.

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 BOP will be contacted immediately with a detailed report of the suspected issue.

Customer Service

The contractor shall describe their customer support service program for institutions with questions about specific EOBs as well as for healthcare providers regarding incorrect claims

(i.e., EDI rejections, HIPAA critical issues). 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.

Quality Assurance

As a condition of a contract, the contractor agrees to be subject to unannounced and recurring quality assurance reviews by the BOP 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 BOP and individual institutions should be clear, concise, and understandable. Any reports sent to the institution should also be sent to the COTR. New procedures affecting the adjudication process should be conveyed to the BOP in writing prior to implementation. The BOP 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 BOP.

The contractor shall submit quarterly reports to the COR detailing any adjustments and errors.

Reports

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

Institution-specific Reports

1. Claims processing errors/adjustments.

2. Top 10 diagnosis codes.

3. Top 10 DRGs.

4. Top 10 reasons for claim denials.

5. Top 10 inpatient diagnosis codes.

6. Top 10 claims “line” denials.

7. Top 10 procedure codes.

Bureauwide Data Reports

1. Claims processing errors/adjustments.

2. Top 10 diagnosis codes.

3. Top 10 DRGs.

4. Top 10 reasons for claims denials.

5. Top 10 inpatient diagnosis codes.

6. Top 10 claim “line” denials.

7. Top 10 procedure codes.

8. Hospital readmission within 30 days for same diagnosis.

9. Top 10 adjusted claims (reason and facility vs.

professional).

10. Claims greater than $35,000 for same diagnosis.

11. Claims by service location.

12. Number of facility claims per institution.

13. Number of professional service claims per institution

(inpatient vs. outpatient).

Other reports will be required by the BOP on an ad hoc basis.

Billing of Adjudication Services

The contractor shall bill each BOP 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. 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.

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 BOP 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 BOP 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

30-day transition-out phase, beginning on the award date, to include:

Within 5 working days after award date: The BOP will schedule a meeting between the out-going contractor, the

BOP, 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 BOP 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 BOP. The

BOP will pay the outgoing contractor’s final bill in accordance to prompt pay.

Period of Performance

The contract term will be for 6 months from February 1, 2014 to

July 31, 2014.