SOO-Medical Provider Network-Medical Bill Processing (MPN-MBP).pdf

DRAFT

STATEMENT OF OBJECTIVES (SOO)

Office of Workers Compensation Programs (OWCP) Nationwide Medical Provider Network (MPN) and Consolidated Medical Bill Processing (MBP) Services

PART 1

GENERAL INFORMATION

1.1 Purpose

The U.S. Department of Labor (DOL), Office of Workers’ Compensation Programs (OWCP) seeks to obtain access to a nationwide medical provider network (MPN) and medical bill processing (MBP) services in accordance with industry standards, applicable laws, and regulations (e.g., the Privacy Act of 1974, as amended (5 USC 522a); Office of Management and Budget (OMB) Memorandum M-06-15), and OWCP rules. The Government envisions a resultant contract under which the Contractor provides OWCP claimants access to a network of medical providers, and in addition, processes and pays medical bills submitted by network providers and non-network providers.

Under the resultant contract, the Contractor will receive payment for: (1) administrative processing of medical bills by out-of-network providers, (2) other direct costs, (3) optional service enhancement projects, and (4) transition-out activities. As for the medical services, whether provided by the Contractor’s in-network physicians or by out-of-network providers, the Contractor will bill for such services directly to the appropriate OWCP benefit fund—not under the resultant Contract.

Section 4.1 provides additional details on the authorities and billing procedures for each OWCP program fund. Reimbursement rates for providers are described in Sections 5.1.9.1, 6.1.1.10, and

6.1.1.11. Except as otherwise specified, the objectives and requirements of this Solicitation apply to each of the OWCP programs identified and supported in the resultant contract.

2.1 Scope/Mission

To provide a nationwide medical provider network and consolidated medical bill processing services to all OWCP programs. Network services provide access to providers in all geographic areas described herein, from which claimants may voluntarily access for treatment of covered injuries and illnesses. Bill Processing services include:

• Interfacing with OWCP National Office and District Office staff

• Providing a full-service centralized mailroom to receive medical bills, attachments, and other workers’ compensation documents such as, but not limited to, claimant and employer correspondence.

• Scanning and data entering bills, attachments and other workers’ compensation documents received in the mailroom.

• Processing bills to payment or denial and issuing Explanations of Benefits

• Capability to reimburse and pay through electronic funds transfer (EFT) where necessary.

• Processing requests for adjustment, authorization of services, suspense resolution, and appeals processing.

• Providing a Call Center to handle inquiries from providers and claimants.

• Providing an interactive voice response (IVR) system to handle automated telephonic inquiries from providers and claimants.

• Providing secure access to images of bills, correspondence, and other documents, and to bill adjudication history and final payment determination

• Sending bill processing detail transactional files (e.g., payment files, bill history files, etc.) based on government-specified formats and timeframes to OWCP.

3.1 Place of Performance

The Government requires the performance of services at production facilities established and maintained by the Contractor in the continental U.S., and at approved alternate (remote) worksites. The Contractor shall submit a request for alternate (remote) worksites to the Contracting Officer (CO) for review and approval. The CO will notify the Contractor in writing within ten (10) workdays of approval/disapproval of the proposed worksite.

The Government requires backup facilities to be established and maintained by the Contractor at a location sufficiently distanced from the primary facility to continue operations in the event of a regional disaster.

4.1 Background

The U.S. Department of Labor (DOL), Office of Workers’ Compensation Programs (OWCP) is responsible for the administration of four (4) occupational injury/illness compensation programs.

The services required may involve one or more of the following programs:

1. Federal Employees Program (FECA)

2. Energy Workers Program (ENERGY)

3. Black Lung Program (BLACK LUNG)

4. Longshore Program (LONGSHORE)

Each program seeks to mitigate the impact of work-related injuries and illnesses for specified workers through the provision and management of medical and other benefits. However, the statutes and regulations that govern the payment of medical and other benefits for each program vary widely.

Medical Services Payments through OWCP Benefit Funds The Contractor will be paid for medical services (both in-network and out-of-network) exclusively through billings to the benefit funds applicable to the workers’ compensation program under which a transaction arises—the Federal Employees’ Compensation Act (FECA)

Fund in the case of payments made under the FECA; Energy Part B(E-B) or Energy Part E (E-E) Funds for transactions made under the Energy Employees Occupational Illness Compensation Program Act (EEOICPA); and the Black Lung (BL) or Disabled Coal Miner (DCM) Funds for transactions arising under the Black Lung Benefits Act (BLBA). Such billings and payments are subject to all laws, regulations, DOL policies, and DOL guidance that apply to providers and contractors seeking payment under the relevant program area (FECA, EEOICPA, or BLBA, Longshore), including but not limited to:

• For transactions through the FECA fund: 5 U.S.C. §§ 8103 and 8123; 20 C.F.R. §§ 10.300-10.337 and 10.800-10.813; and Federal (FECA) Procedure Manual Part 3;

• For transactions through the Energy Part B (E-B) or Energy Part E (E-E) fund:

42 U.S.C. §§ 7384t and 7385s-8; 20 C.F.R. §§ 30.400-406 and 30.700-714;

Federal (EEOICPA) Procedure Manual Chapters 28, 29 and 30;

• For transactions through the Black Lung (BL) or Disabled Coal Miner (DCM) funds: 26 U.S.C. §§ 9501 et seq. , and 30 U.S.C. § 901; 20 C.F.R. §§ 725.701- 720;

• For transactions through the Longshore Special Fund: 33 U.S.C. §§ 907, 944;

20 C.F.R. §§ 702.401-.417.

Each of the workers’ compensation programs identified above contains regulations providing DOL the right to review, inspect, and audit pending reimbursement requests and payments made from the above-listed funds to providers or contractors in accordance with the requirements of Federal Claims Collection regulations, at 29 C.F.R. §§ 20.19 to 20.62. Such reviews, inspections and/or audits may be conducted directly by DOL or by the GAO, OIG, or a third-party contractor, on an ad hoc or routine basis. If DOL determines that reimbursement should not be made or that past payments made to the Contractor resulted in a payment in excess of that to which the Contractor should have been entitled, under the applicable laws and regulations governing the transaction, the Contractor understands and agrees that DOL, at its discretion, may deny reimbursement and may demand the return of the excess payment in accordance with applicable law.

Furthermore, the Contractor understands that DOL may collect the excess payment by deducting the overpaid amounts from current and future billings to the same fund (FECA, Energy Part B or E, BL, or DCM) from which the excess payment was made. Such excess payments may include instances where a payment made by DOL is subject to adjustment due to reversals and/or corrections of transactions; instances involving improper classification of medical services; or another circumstance where the payment was in excess of the proper amount payable under the applicable statute and its regulations, or applicable DOL policy and guidance. The Contractor agrees to cooperate with such reviews, inspections, and/or audits and to return/refund any excess payments (whether to in-network or out-of-network providers) and make all changes in its system required to prevent any further errors. The Contractor acknowledges that DOL may review any past Contractor transactions at any time to determine inaccuracies or errors.

DOL will provide the Contractor with notice of the excess payment and an opportunity to contest the finding of an excess payment in accordance with the regulations and guidance applicable to each benefit fund to resolve disputes in the program area under which the excess payment arose (i.e., the FECA, EEOICPA, or BLBA).

DOL's right to review reimbursement requests and past payments and related transactions and recover excess payments from the Contractor is separate and, in addition to any rights DOL may have under the Inspection/Acceptance and Audit clauses in the resultant Contract, see FAR 52.212-4(a), 52.212-4(i)(5), and 52.212-5(d), and also, in addition to DOL's right to audit the Contractor to detect fraud, waste, or abuse.

Any disagreement or dispute about reimbursements or payments to providers under OWCP benefit funds regulations and policies is governed exclusively by the respective OWCP benefit fund’s laws, regulations, policies, and guidance, and are not disputes subject to the Contract Disputes Act, 41 U.S.C. Chapter 71 or Federal Acquisition Regulation (FAR) Subpart 33.2, Disputes and Appeals.

Recent History of OWCP Benefit Funds Payments and Transactions In a recent one-year period, OWCP processed 3,597,795 medical bills. The total amount paid in medical benefits was $1,722,126,604. These were distributed among the programs as follows0F

1:

• FECA: 71% of total bills processed and 38% of total payments1F

2:

o 85% of FECA bills processed for Medical Services and 15% of bills processed are for Ancillary Medical Services

• ENERGY: 27% of total bills processed and 61% of total payments2F

3:

o 22% of Energy bills processed are for Medical Services and 78% of bills are for

Ancillary Medical Services); and

• BLACK LUNG: 2% of total bills processed and 1% of total payments:

o 94% of Black Lung bills are for Medical Services and 6% of bills are for Ancillary

Medical Services

• Longshore Program (LONGSHORE) 0% of total bills processed.

Payments Under The resultant Contract DOL intends to make payments under the resultant contract only for out-of-network medical bill processing fees, other direct costs (ODCs), optional service enhancements, and transition-in

1 Ancillary Medical Services for all OWCP programs include such services and items as Durable Medical Equipment (DME), home health services, and non-medical provider services (e.g., home and vehicle modifications).

2 For the FECA program only, claimant reimbursements, contracted second opinion examinations and independent medical examiners, medical advisor case reviewers, and contracted nurse and vocational rehabilitation services are not included in either the Medical Services or Ancillary Services data. These service invoices are to be processed in-house by the FECA program.

3 The Government notes that a high majority of Energy program payments are issued to non-PPO providers, such as but not limited to, providers of home health care and vehicle modifications, activities. These payments are subject to applicable provisions for contract payments, including the FAR and the Contract Disputes Act.

4.1.1. Program Overview

The FECA program as the largest of OWCP’s four programs is responsible for payment of medical and other benefits for federal workers injured or made ill on the job. It also facilitates return-to-work for workers with work-related injuries or illnesses who can return to work. The FECA program is responsible for ensuring that benefits are promptly paid and help claimants return to work as soon as possible to minimize their period of disability.

The Energy program is responsible for providing lifetime medical benefits to accepted claimants who typically have severe and often several covered illnesses. One of the most common benefits provided to Energy claimants is home health care, which, unlike most other federal programs, is not capped by time and can continue if medically necessary and it provides relief to the claimant.

Most of the claimant population is elderly, and many claimants are nearing the end of their lives.

The Black Lung program administers claims filed under the Black Lung Benefits Act and provides compensation to coal miners who are totally disabled by pneumoconiosis arising out of coalmine employment. The program also provides eligible miners with medical coverage for the treatment of lung diseases related to pneumoconiosis. The Black Lung beneficiary population is relatively small when compared with the FECA beneficiary population. Often, Black Lung beneficiaries live in rural areas where they have limited access to medical practitioners, facilities, and other resources. Most Black Lung beneficiaries are over the age of 50 years.

The Longshore program is charged with minimizing the impact of land based, maritime employment injuries and deaths on injured employees and their families by ensuring that workers’ compensation benefits are provided promptly and properly under the Longshore and Harbor Workers' Compensation Act (LHWCA), Defense Base Act (DBA), Non-Appropriated Fund Instrumentalities Act and the Outer Continental Shelf Lands Act. The role of the Longshore program is to oversee benefit delivery by the self-insured employers and insurance carriers it authorizes and regulates.

5.1 Performance Objectives

The objective of this requirement is to provide a nationwide medical provider network and medical bill processing services to ensure timely and accurate claims adjudication and provision of benefits, minimize service interruptions and delays, and maximize claimant satisfaction. The contractor shall obtain approval from DOL to assume operations (also known as “Go-Live”) only after the government has certified that all testing in the approved Implementation Plan is successfully completed, and the solution is fully functional.

Specific objectives for the Medical Provider Network:

• Covered workers have timely and convenient access to medical providers, which they need and voluntarily select to perform examination, treatment, impairment evaluations, reports, and related services for accepted injuries and illnesses3F

4.

4 Within the OWCP programs, “accepted conditions” are utilized to establish eligibility for services based on ICD

Specific objectives for the Medical Bill Processing:

• Efficient, accurate, and timely bill processing for OWCP providers and claimants.

Accurate processing refers to the correct implementation and maintenance of business rules and practices for each OWCP program and the application of industry standards for medical bill processing.

• Reimbursement of only those medical services approved for claimants’ accepted conditions.

• Timely authorization for covered benefits.

• Achieving and reporting cost savings resulting from the standardization of functions across OWCP programs and the application of state-of-the-art capabilities, including, but not limited to, utilization limits, fee schedules, and other industry standards.

• Responsiveness to customer inquiries and requests.

• Incorporation and maintenance of industry standard bill processing capabilities, including but not limited to, clinical guidelines for medical treatment and prescriptions, fraud, and abuse protection methodologies, and National Correct Coding Initiative (NCCI).

• Providing standardized reports for contract management, production, and trend analysis.

• Providing OWCP management access to all stored data to enable the tracking and analysis of the information necessary for identification of program trends, service limitation, etc.

• Establishing a framework for continuous improvement.

Complying with Federal requirements for financial and benefit systems, including but not limited to Federal Financial Management Improvement Act (FFMIA) Core Financial System Requirements: http://www.gao.gov/new.items/d05225g.pdf, and FFMIA Benefit System Requirements: http://www.gao.gov/new.items/d0422g.pdf.

• Implementing bill processing improvements that incorporate advancements in the field (e.g., International Classification of Diseases version changes and regulatory changes).

5.1.1 Reserved.

5.1.2 Access to Preferred Provider Networks/Data

5.1.2.1 The Contractor shall furnish medical providers who are already enrolled in existing PPO networks, or establish a new PPO network, to whom OWCP claimants can be referred for medical treatment of their injuries or occupational illnesses in exchange for payment at the negotiated rate per their network(s) up to the OWCP Fee Schedule amount.

codes, state guidelines (where relevant), and OWCP business rules for how medical conditions and treatments are related.

http://www.gao.gov/new.items/d05225g.pdf http://www.gao.gov/new.items/d0422g.pdf

5.1.2.1.1 The Contractor shall provide access to a searchable database of the medical providers in existing or new PPO networks to whom OWCP claimants can be referred for treatment.

5.1.2.2 The Contractor shall provide the ability to collect and process all required information from in network and out of network medical providers. At OWCP’s request, for those providers who are not a member of an existing PPO the Contractor shall enroll them in the PPO network and/or register as a non-network biller. For new enrollments, collection of provider information (e.g., licensure, certification, EFT (ACH), taxonomy, TIN Matching, W9, LEIE, etc.) is preferred, and required when in accordance with industry regulations and/or state and federal mandates.

5.1.2.2.1 For out of network providers using billing agents and/or Third-Party Billers, the contractor shall link the billing agent and/or third-party biller to the medical provider giving service.

5.1.2.3 For out-of-network providers, the Contractor shall provide comprehensive outreach and training strategies to support provider use of new bill processing system prior to go-live of services under the resultant contract, and to support ongoing operations.

5.1.2.4 The Contractor shall utilize Contractor-obtained and Government-provided lists to ensure payment of medical bills is not made to excluded, suspended, and debarred providers.

5.1.3 Claimant Eligibility

5.1.3.1 The Contractor shall receive and process all data within Government program eligibility files and return acknowledgement and error files in the approved Government formats. Utilize the data for bill processing functions, update claimant eligibility data such as claim status and accepted condition, available to the Government, and configure applicable claimant indicators based on Government specifications.

5.1.4 Authorization

5.1.4.1 The Contractor shall provide a process whereby a provider requesting authorization for treatment can upload/enter/call-in the request for authorization, which may be transmitted (depending on the requested procedure and the Government’s criteria) to a Government employee for adjudication, and where the vendor will transmit the adjudicated response back to the requestor and input that response into the medical bill processing system.

5.1.4.2 The Contractor shall accept and process emergency authorization requests.

5.1.4.3 The Contractor shall allow authorization information, such as the request, status, associated bills, and letters, to be accessible and searchable through an online portal by user groups defined by the Government.

5.1.4.4 The Contractor shall provide portal capability to search and download authorization images/attachments according to Government requirements.

5.1.5 Central Mailroom/Document Imaging/Bill Scanning/Data Entry

5.1.5.1 The Contractor shall provide a central mailroom infrastructure (facility, hardware, software) to receive paper documents (medical reports, bills, and correspondence), and scan/digitize, identify to which OWCP case file the documents should be associated with and index, and transfer nightly batches of such files to the Government.

5.1.5.1.1 The infrastructure provided by the Contractor shall permit the widest latitude in remote work capability to allow for uninterrupted services.

5.1.5.2 If optimal for the offeror’s operations, the Contractor shall develop and propose a plan to transition and consolidate all existing program PO Boxes and/or mailing addresses.

5.1.5.3 The Contractor shall return medical bills and non-bill documents, as specified by the Government, to the provider or claimant, and where identified, to Government designated office(s).

5.1.5.4 The Contractor shall provide portal access, print, and download capabilities for all document images and bill processing data (migrated and new) through the full adjudication cycle for authorized users, including but not limited to OWCP and program staff, Government auditors and Government -contracted auditor companies.

5.1.6 Bill Processing

5.1.6.1 The Contractor shall provide bill processing services that include capabilities to ingest and process electronic and paper bills (via the mailroom) with all required medical attachments, including but not limited to medical reports and physician progress notes.

5.1.6.2 The Contractor shall coordinate benefits with federal, state, and commercial insurance carriers and process carrier reimbursements. Coordinating benefits may include the sharing of claimant eligibility files using specific data templates and processing unique bill forms for payment.

5.1.7 Bill Resolution/Edits and Audits

5.1.7.1 The Contractor shall use industry standard edits (including but not limited to National Correct Coding Initiative (NCCI), CMMS publicly available Medically Unlikely Edits (MUEs), utilization review (UR), CPT guidelines from the American Medical Association etc.) wherever possible to ensure correct processing of bills and to reduce the risk of fraudulent billing.

5.1.7.2 Where possible, the Contractor shall use industry recognized bill edits, adjustment reason codes, and EOB language for the purpose of bill and payment processing.

5.1.7.3 The Contractor shall support the use of appropriate edits as determined by the Government, as well as additional, Government-specified edits to the bill processing system where necessary.

5.1.7.4 The Contractor shall generate, track, and provide notifications to providers and claimants that provide an explanation for any payment-related items, such as issues or other information, and why a bill was deficient, identifying all additional information needed for bill processing.

5.1.7.5 The Contractor shall develop and host a web portal to allow authorized users to view bill resolution associated actions, such as end-to-end transaction history, explanation of benefits, and edit/audit details and bill dispositions.

5.1.7.6 If and where needed, the Contractor shall have the ability to implement a process to handle exception/bill suspense scenarios, and to store and modify, through configuration, Government approved edit and audit rules, as well as continuously monitor/evaluate transactions to identify issues or proposed changes for Government review.

5.1.8 Fiscal Services (Payment Cancellations, Adjustments, Voids, Credits and Payments)

5.1.8.1 The Contractor shall perform adjustments, voids, cancellations, check trace, re-issues and credit transactions for previously paid bills and bill corrections; track adjustment transactions and reasons; and maintain an online capability for Government staff, providers, and claimants to submit adjustment requests and view the complete history of a void and/or adjusted bill.

5.1.8.2 The Contractor shall implement features on the web portal to enable providers and claimants to view remittance voucher information and for authorized Government users to view all transactions from the time of the receipt of the bill to the time of payment or denial.

5.1.8.3 The Contractor shall implement and maintain an accounting system to process Government payment files to include, but not limited to, setting up the processes required to handle RV, EFT, Check, and 1099 processing at a frequency and format defined by the Government.

5.1.9 Bill Pricing

5.1.9.1 The Contractor shall implement Government approved OWCP Fee Schedules, contractual pricing, and specifications to calculate allowed fees and various pricing logically by bill type - such as inpatient, outpatient, and professional. The OWCP Fee Schedule is publicly available on the OWCP Agency page at www.DOL.gov and is incorporated by reference. DOL updates the OWCP Fee Schedule periodically with economic increases and decreases as appropriate. Any new version of the OWCP Fee Schedule is hereby incorporated by reference immediately when published. The Contractor shall use the most recent OWCP Fee Schedule for all calculation of fees.

5.1.9.2 The Contractor shall implement a solution that can bypass the fee schedule or modify the fee reimbursement amount, as required by the Government.

http://www.dol.gov/

5.1.9.3 The Contractor shall implement a series of approved edits and audits with all pricing methodologies applied to bills to ensure that only valid bills for eligible claimants and covered services are reimbursed.

5.1.9.4 The Contractor shall maintain and utilize current Government approved reference files to support pricing, such as CMS Fee Schedules, 3M Grouper/Pricing (DRG), AMA Procedure File, Therapeutic Classes (TC), Nation Drug Codes (NDC), Generic Code Numbers (GCNs), Dental Procedure File (CDT), AMA Diagnosis File (Covered and Non-Covered), and Revenue Center Code Update File (RCC)

5.1.9.5 The Contractor shall process PPO and non-PPO bills, which includes keying/scanning/digitizing and transmitting the bills and medical reports. The Contractor shall pay all providers directly, separately requesting from OWCP the full amount of the medical services paid, and the aggregate transaction fees described below, and produce a bill history report by individual claim.

5.1.10 Data Transmissions

5.1.10.1 The Contractor shall transmit and index incoming/submitted documents regardless of submission method, such as bills, authorizations, associated bill and authorization attachments, and non-bill documents, to the Government per defined requirements.

5.1.10.2 The Contractor shall implement and maintain integration with OWCP systems to exchange data and authenticate users per Government requirements. Currently, three OWCP applications may be integrated.

5.1.11 Fraud, Waste and Abuse Detection

5.1.11.1 The Contractor shall create and maintain a Fraud, Waste and Abuse Detection System (FWADS) using a web-based portal that mines claim and provider data to identify irregularities in data and billing patterns often indicative of fraud, waste, and abuse.

5.1.12 Operational Reporting

5.1.12.1 The Contractor shall implement online reporting self-service to allow users to alter the presentation of report data through user-defined criteria, as well as print and download documentation from the portal.

5.1.12.2 The Contractor shall provide reporting tools that allow the generation of standard scheduled reports according to Government requirements, with the ability to download reports for further analysis.

5.1.12.3 The Contractor shall provide reporting capability to illustrate transactional performance by functional area, such as provider enrollment, authorizations, bill processing, and mailroom to include, but not limited to system monitoring, performance analysis, service utilization analysis, management queries, and bill processing transactional performance.

5.1.13 Customer Service/Call Center/Interactive Voice Response (IVR)

5.1.13.1 The Contractor shall provide a staffed Call Center facility available to claimants, providers, and employing agency personnel with the capability to review and answer inquiries about the status of bills, claims, administrative functions, and other areas as defined by the Government.

5.1.13.2 The Contractor shall develop and maintain an interactive voice response (IVR) system to ensure that clients have 24-hour access to updates on eligibility, limitations, bill pay and authorization status, and general instructions.

5.1.13.3 The Contractor shall provide on-demand access for authorized Government users to call notes and call recordings.

5.1.14 Web Portal

5.1.14.1 The Contractor shall implement a public and secured private portal, based on Government specifications, to support all Government and external users, such as providers, claimants, auditors, and authorized representatives.

5.1.14.2 The Contractor shall ensure that the portal provides authorized users the following features:

5.1.14.2.1 Ability to locate a MPN physician within a geographic location by entering, at a minimum, the specialty and zip code.

5.1.14.2.2 All payment/denial information relative to the submitted and adjudicated bills, to include the ability to access documents attached to the bills for viewing and inquiry, authorization request information, and other bill processing information and reports as defined by the Government.

5.1.14.3 The Contractor shall implement and maintain interfaces with Government defined systems, such as those that handle eligibility, compensation, and user authentication.

5.1.15 Outreach/Training

5.1.15.1 The Contractor shall provide training that covers all facets of the system and is customized by user groups (internal and external customers) prior to go-live, as well as conduct ongoing training needs in operations to the Government staff users as it relates to new implemented system technology.

5.1.15.2 The Contractor shall provide a communication process by which providers, claimants, and/or DOL staff can contact Outreach/trainers for support and assistance.

5.1.15.3 The Contractor shall implement a method to review and evaluate output/products of training and outreach activities.

5.1.15.4 The Contractor shall provide proactive, industry and trend-based recommendations to the Government related to future training needs based on evaluation and review of feedback from all stakeholders.

5.1.15.5 The Contractor shall develop and issue ongoing outreach campaigns on proper and best practices in billing.

5.1.16 General

5.1.16.1 It is the Government’s preference to utilize Commercial Off the Shelf (COTS) products in performance of services. The Government anticipates some customization shall be necessary to commercially available services.

5.1.16.2 The Contractor shall provide assessments and strategic guidance on the bill processing system to identify information security system vulnerabilities and policies as well as recommendations for remediation. Once a remediation plan has been agreed upon, perform remediation activities per a mutually agreed upon timeline.

5.1.16.3 The Contractor shall ensure successful transition from incumbent Contractor in areas, such as, but not limited to, data migration approach/execution/maintenance, detailed requirements gathering sessions, requirements traceability matrix, assumption of operations approach and execution, and toll-free number/PO Boxes transfer.

5.1.16.4 The Contractor shall ensure that the system, data transmission processes, and associated processes conform to the current DOL implementation of Federal information Security Guidelines.

5.1.16.4.1 The Contractor shall ensure compliance with all applicable Federal standards including but not limited to NIST 800-53 Rev. 5, NIST 800-171 Rev. 2, NIST 800-63 and all subparts.

5.1.16.5 The Contractor shall ensure that any Cloud hosting of components must be FedRamp authorized and maintain the controls required by FedRamp for authorization.

6.1 Operating Constraints

6.1.1 Common to All Programs

6.1.1.1 Servicing providers must be geographically distributed within the Metropolitan Statistical Areas (MSA) in the 50 states, the District of Columbia, Puerto Rico, and Indian tribal areas to provide availability of sufficient medical providers to cover the needs of OWCP-covered workers. The Government’s goal is to provide nationwide access to qualified treating physicians and medical providers through the Preferred Provider Organization (PPO) networks the vendor can directly access. Related to Performance Objective 5.1.2 Access to Preferred Provider Networks

6.1.1.2 The Contractor shall rescan poor quality source documents to improve quality, and if quality cannot be improved, provide a means to indicate for all final images that are not usable for manual and automated processing, that the final images are the “best scan possible." Related to Performance Objective 5.1.5 Central Mailroom/ Document Imaging/ Bill Scanning/ Data Entry

6.1.1.3 The Contractor shall provide and maintain all infrastructure (facilities, hardware, software) necessary to receive USPS, courier deliveries of parcels, and interface with and/or receive files from the Government containing bills, their attachments, correspondence, and other documents for all programs, for appropriate processing within the Government specified timeframes. Related to Performance Objective 5.1.5 Central Mailroom/ Document Imaging/ Bill Scanning/ Data Entry

6.1.1.4 The Contractor shall forward foreign and Panama bills to the Government for processing and receive the resulting payment data for inclusion in the WCMBP bill history. Related to Performance Objective 5.1.6 Bill Processing

6.1.1.5 The Contractor shall support third party liability (TPL) for all programs. The DFELHWC process uses a TPL indicator (case status), and both DEEOIC and DCMWC use an offset indicator. The Contractor shall not pay bills denied during med-offset hold periods if resubmitted again after claimant obligations have been met. Related to Performance Objective 5.1.6 Bill Processing

6.1.1.6 The Contractor shall implement system controls, policies, and regulations for all OWCP programs. Provide recommendations to the Government on any changes to better align with industry standards. Related to Performance Objective 5.1.6 Bill Processing

6.1.1.7 The Contractor shall recover overpayments from network and non-network providers and return funds to the Government as specified by the Government Programs. Related to Performance Objective 5.1.8 Fiscal Services (Payment Cancellations, Adjustments, Voids, Credits and Payments)

6.1.1.8 The Contractor shall backup withhold future payments at the IRS percent rate for TINs identified by the IRS notice. Follow all withholding processes as specified in the latest IRS Publication 1281 and IRS Publication 594. Related to Performance Objective 5.1.6 Bill Processing

6.1.1.9 The Contractor shall process all billing forms to payment or denial within 15 calendar days from receipt of electronic and hardcopy (paper), and document bill disposition via bill history files transmitted to the Government. Related to Performance Objective 5.1.8 Fiscal Services (Payment Cancelations, Adjustments, Voids, Credits and Payments)

6.1.1.10 The Contractor shall be the sole billing agent for all covered medical services provided to OWCP claimants, whether by its in-network providers or out of network providers. No payments shall be made under the resultant contract for medical services or for processing in network medical bills (no administrative fee shall be paid for in network medical bill processing). Payments to in network providers shall be up to the maximum allowable OWCP Fee Schedule, as defined in Performance Objective Section 5.1.9.1.

The Contractor shall submit a file of payable in network provider charges to OWCP, for payment by Treasury to the Contractor from the appropriate benefit funds. It shall be the contractor’s responsibility to ensure that in network providers receive appropriate payment in accordance with the terms of the contractor’s engagement with in-network providers. The payment of medical services from benefit funds is not subject to FAR 52.212-4(g). DOL will not pay any bill greater than the OWCP Fee Schedule, defined in Performance Objective Section 5.1.9.1. The Government will not be held responsible for any costs associated with re-processing of PPO provider bills. Related to Performance Objective 5.1.9 Bill Pricing

6.1.1.11 The Contractor shall make payment directly to out of network providers, up to the maximum allowable OWCP Fee Schedule, as defined in Performance Objective Section 5.1.9.1, using applicable OWCP benefit fund laws, regulations, policies, and business rules. The Contractor shall submit a file of payable non-PPO provider charges to OWCP as a Third-Party Biller, for payment by Treasury to the Contractor from the appropriate benefit funds. The payment of medical services from benefit funds is not subject to FAR 52.212-4(g). To cover the administrative costs of non-PPO bill processing, the Government envisions a fixed fee, per non- PPO bill processed, but may consider other pricing methodologies that are in keeping with industry standard. The Contractor shall invoice the Government separately for the administrative processing fees, which are subject to FAR 52.212-4(g). The Government will not be held responsible for any costs associated with re-processing of non-PPO provider bills. Related to Performance Objective 5.1.9 Bill Pricing

6.1.1.12 The Contractor shall identify bills (for payments under this contract) which are subject to the Prompt Payment Act (PPA) and ensure such bills are paid in accordance with the Act using the interest formulas established by the U.S. Treasury. Related to Performance Objective

5.1.9 Bill Pricing

6.1.1.13 The Contractor shall maintain call center phone call conversation recordings and notes for the life of the call center operations for all OWCP programs. These recordings shall be cross-referenced to the case/claimant numbers and daily call logs (e.g., with a date time stamp) and must be reviewable in a nonproprietary audio format and made available to the Government upon request. Related to Performance Objective 5.1.13 Customer Service (Call Center/ Interactive Voice Response (IVR))

6.1.1.14 The Contractor shall support audits (including ad hoc audits) performed by DOL and its independent auditors, which may include IT security, financial statements and FISCAM, GAO, OIG, KPMG, among others. Support all auditor requests, including but not limited to, documentation requests, demos, demonstration of documented policies procedures together with documented evidence of implementation, and/or medical bill history data. This may require the creation of ad hoc reports, copies of code snippets, explanation of existing and/or creation of new documents, etc. Related to Performance Objective 5.1.16 General

6.1.1.15 The Contractor shall have an independent auditor, effective at commencement of operations, to perform an annual SSAE-18 (or similar audit as is designated by DOL based on any updated auditing standards) audit resulting in a SOC I Type 2 report for the period specified by the U.S. Department of Labor (DOL). The independent auditors and the vendor will need to provide supporting documentation for the audit and DOL will work with the vendor to identify all applicable controls to be tested and included in the report. The final version of this report will be due in September of every year. Related to Performance Objective 5.1.16 General

6.1.1.16 The Contractor must make provider information available to support investigations and prosecutions. Provider information may include (not limited to) enrollment date(s), inactive date(s), tax identification numbers (TIN), National Provider Identifier number (NPI), transaction history, payment history, banking information, ownership information, affiliated entity providers, claimants serviced, etc. Related to Performance Objective 5.1.16 General

6.1.1.17 The Contractor shall provide and use separate development, training and testing environments that replicate the production processing capabilities. The environment(s) used for System Integration Testing, Performance and Volume Testing, User Acceptance Testing and Parallel Testing shall exactly replicate the production environment and allow the Government to perform comprehensive functional and process testing, and user interface testing and validation.

Environments are to be updated within a refresh cycle as agreed to by the Government. Related to Performance Objective 5.1.16 General

6.1.1.18 The Contractor shall maintain and make immediately accessible 7 years of bill history (to include complete history of paid, denied, adjustments, reports and reversal of bills and all bill-related document images) in a form that can be immediately accessed by users at any time.

This includes all data within any bill history provided by DOL, including any bill history prior to contract award. All other data shall be archived for retrieval by the Contractor upon Government request. Related to Performance Objective 5.1.16 General

6.1.1.19 The Contractor shall provide an electronic means and user licenses to access reference materials (e.g., ICD-9/10CM, Health Care Common Procedural Coding System [HCPCS], CPT, American Dental Association Current Dental Terminology (ADA CDT), Surgical Cross Coder, Physician’s Desk Reference [PDR], Merck Manuals, Diagnostic Relational Grouping Expert (DRG Expert, etc.), and web-based references ICD-9/10 and all other future versions Expert and Encoder Pro; for Contractor staff and for Government staff as requested in Section J. Related to Performance Objective 5.1.16 General

6.1.1.20 The Contractor shall adhere to requirements of the DOL Computer Security Handbook/Cybersecurity Policy Portfolio. They must adhere to the requirements for a 3rd party system, including quarterly reporting and annual updates to all security policy documents. A system security plan, incident response plan, contingency plan and other core security documents will need to be reviewed and approved before operations commence.

6.1.1.21 Technical Management

6.1.1.21.1 The Contractor shall provide technical and management plans, such as but not limited to Project Management Plan, Requirements Management Plan, Risk Assessment Plan, Data Migration Plan, Quality Control Plan, Training and Outreach Plan, User Acceptance Plan, Change Request Plan, Incident Management Plan, Change Management Plan, Test Management Plan, such as parallel testing, performance testing, volume testing, and user acceptance/verification testing, Contingency Plan, Assumption of Operations approach, Transition In Plan, and Transition Out Plan to ensure proper management and oversight of implementation and operations. All plans require Government approval.

6.1.1.21.2 The Contractor shall establish a process, per Government requirements, to manage, implement, and maintain change requests identified during operations phase. Process is to be established by the Contractor and approved by the Government prior to the start of operations.

6.1.1.21.3 The Contractor shall establish a process, per Government requirements, to manage incident/defect requests submitted by the Government during operations phase. Process is to be established by the Contractor and approved by the Government prior to the start of operations.

6.1.1.21.4 The Government prefers that the Contractor is accredited with, at minimum, Capability Maturity Model Integration (CMMI) Level 2 and applicable International Organization for Standardization (ISO) accreditations, or similar, to successfully manage implementation and operations phases.

6.1.2 Specific to FECA Program

6.1.2.1 The Contractor shall use state industry guidelines/edits based on place of service for FECA program’s bill processing and an exception-based process for approving beyond the state edits/guidelines. Related to Performance Objective 5.1.7 Bill Resolution/ Edits and Audits

6.1.2.2 The Contractor shall include Government criteria in processing FECA’s Administratively Reviewed cases. This case status will be identified by a flag in the eligibility file. This case status allows payment up to a specified dollar amount per case and requires transmission of a daily payment report to FECA. Related to Performance Objective 5.1.7 Bill Resolution/ Edits and Audits

6.1.2.3 The Contractor shall include Government criteria in processing bills where a CA-15 or CA-16 form is associated with the case. The form association will be identified by a flag in the eligibility file. Where the flag is present, payment of services for a specified number of days is allowed regardless of the case status. Related to Performance Objective 5.1.7 Bill Resolution/ Edits and Audits

6.1.3 Specific to Energy Program

6.1.3.1 The Contractor shall generate, print, and distribute medical benefit cards and welcome packages to all existing and new Energy program claimants, including authorized representatives, in accordance with the Government specifications and criteria. Related to Performance Objective 5.1.3 Claimant Eligibility

6.1.3.2 The Contractor shall receive and process claimant submitted bills to reimburse for claimant out-of-pocket expenses. The vendor will use attached documentation (e.g., bill forms, medical reports, itemizations, etc.) to develop and code billed services identified on the claimant-submitted bill forms. Related to Performance Objective 5.1.6 Bill Processing

6.1.3.3 The Contractor shall require bill attachments for services as defined by the Government.

Related to Performance Objective 5.1.6 Bill Processing

6.1.4 Specific to Black Lung Program

6.1.4.1 The Contractor shall generate, print, and distribute annual and permanent medical benefit cards and welcome packages to all existing and new Black Lung program claimants, including authorized representatives, in accordance with the Government specifications and criteria.

Related to Performance Objective 5.1.3 Claimant Eligibility

6.1.4.2 The Contractor shall receive, and process claimant submitted bills to reimburse for claimant out-of-pocket expenses. The vendor will use attachments (e.g., bill forms, medical reports, itemizations, etc.) to develop services on the claimant-submitted bill forms. Related to Performance Objective 5.1.6 Bill Processing

6.1.4.3 The Contractor shall require bill attachments for services as defined by the Government.

Related to Performance Objective 5.1.6 Bill Processing

6.1.5 Specific to Longshore Program

At this time the Department is not applying any of the requirements or rules of the Longshore Program and no services are expected to be provided to this program. The Department may add this program at a future date.

6.1.6 Specific to Both Black Lung and Energy Programs

6.1.6.1 The Contractor shall use treatment guidelines for Energy and Black Lung programs’ bill processing and OWCP Treatment Suites where treatment guidelines do not exist. Related to Performance Objective 5.1.7 Bill Resolution/ Edits and Audits

6.1.6.2 The Contractor shall receive and process Prompt Payment Act (PPA) bills within 21 calendar days from PPA date. For SBA PPA bills process within 15 calendar days of receipt date. Related to Performance Objective 5.1.8 Fiscal Services (Payment Cancelations, Adjustments, Voids, Credits and Payments)

6.1.6.3 The Contractor shall implement Government approved fee schedules, contractual pricing, and specifications to calculate allowed fees and various pricing logically for Energy and Black Lung Program travel, prompt pay and claimant reimbursement (e.g., out of pocket expenses) bills. Related to Performance Objective 5.1.9 Bill Pricing

6.1.6.4 The Contractor shall identify Black Lung and Energy programs’ bills subject to the Prompt Payment Act (PPA) and make payment in accordance with the Act using the interest formulas established by the U.S. Treasury. Related to Performance Objective 5.1.9 Bill Pricing

6.2 Performance Metrics and Service Level Agreements

The Contractor’s performance shall meet, at a minimum, the following performance metrics and Service Level Agreements (SLAs):

See Table Below:

SOO Reference Performance Metric and Threshold

Criteria

Exclusions

Contract Transition – Ongoing Documentation Delivery (5.1.16.3)

Deliver acceptable updates to Government-approved documentation each quarter.

Timely deliverables are documented and accepted by the Government within 5 business days of the start of each Federal fiscal quarter.

Deliverables are 95% timely and accepted by the Government.

Calculated as number of deliveries completed within 5 business days for deliverables such as, but not limited to, Requirements Specification updates and Workers' Compensation Medical Bill Process Operations Manual updates for each federal fiscal quarter.

Applicable for the reporting months of Oct, Jan, Apr, Jul for each federal fiscal year.

When a new Standard Operating Procedure (SOP) is necessary, all documentation shall be updated within the Government-approved timeframe(s) for the action/change that needs a new SOP.

Contract Transition – Performance Deficiency Correction – Corrective Action Plan (6.1.1.21)

(1) Upon identification by the Government of a deficiency in performance, develop a corrective action plan for delivery within 3 business days

(2) Modify and finalize the corrective action plan within one workday after receiving Government feedback.

(3) Notify the government CO, Deliverables are 95% timely.

Measured for:

1) Upon identification by the Government of a deficiency in performance, develop a corrective action plan for delivery within three (3) business days

2) Modify and finalize the corrective action plan within one (1) workday after receiving Government feedback.

3) Notify the government CO, COR and PMO within 24 hours if it identifies a risk to successful performance at adjusted levels.

Mutually agreed upon timelines.

COR and PMO within 24 hours if it identifies a risk to successful performance at adjusted levels.

Contract Transition – Performance Deficiency Correction – Corrective Action Plan (6.1.1.20)

Maintain compliance with 3rd party system requirements at 100%.

Government certification of operational capability is maintained at 100%.

Measured as deviations from the operational certification and FISMA requirements.

N/A

Contract Transition – Performance Deficiency Correction – Corrective Action Plan (6.1.1.21)

Immediately notify the Government when any…