SOW - ELECTRONIC CLAIMS.docx

SCOPE OF WORK

The Contractor shall provide third party billing services through a Virtual Private Network (VPN) from the Contractors headquarters in order to fulfill the requirements of the contract.

The Contractor shall obtain an Interconnect Security Agreement (ISA) with the Indian Health Services (IHS) in order to gain access to IHS network system.

The Contractor shall complete billing by accessing information by using the third party billing package that was inputted during the registration, Electronic Health Record (EHR), and coding queue process.

The Contractor shall ensure that payer information is accurate and sequenced appropriately when processing a claim to guarantee the bill is submitted to the proper payer. This includes identifying when employment/accident related visits would designate a different responsible payer source from the patient's usual primary payer.

The Contractor shall verify; input, and/or adjust clinic types, visit types, bill types, proper mode of export; release of information, assignment of benefits, accident information, and referring physician information whenever necessary.

The Contractor shall split claims when appropriate.

The Contractor shall ensure that appropriate providers are indicated and shall verify and assign proper revenue codes if necessary.

The Contractor shall ensure proper dates of service for ancillary services and the Evaluation and Management services.

The Contractor shall handle and correct all error prompts that appear on a particular billing page.

The Contractor shall identify and compile defects/errors in coding; data entries and other items in the billing process, charts and clinic visits by using the flagging/tracking process and these defects/errors shall be returned to the service unit for clarification and/or corrections. After corrections have been made the claims shall be re-submitted.

The Contractor shall use the Accounts Receivable (A/R) package (IHS-RPMS) to complete payment posting and follow-up on unpaid claims.

The Contractor shall communicate new billing requirements and any issues found on follow up with Patient Registration, Visit coding or medical documentation with the Business Office Manager.

The Contractor shall maintain identified corrective action received from the third party payers to be shared or communicated with the Business Office Manager for review, possible consideration and appeal for payment.

The Contractor shall ensure that all applicable forms are submitted and adequately reflect the services rendered.

The Contractor shall maintain current documentation and files for all third party utilization review activities in appropriate files, binders, etc.

The Contractor shall be responsible for timely posting of payments and nonpayment adjustments received from insurance claims filed.

The Contractor shall ensure filing of all Explanation of Benefits (EOB's) in chronological order, and posting to the correct patient accounts.

The Contractor shall generate correspondence on appeals and denials and shall maintain compliance with Third Party Internal Controls policy.

Contractor Business Responsibilities:

The Contractor shall be responsible for reporting all taxes from wages earned under the contract to the appropriate Federal, State and local agencies.

The Contractor shall be responsible for his/her own transportation, travel and per diem expenses in the performance of this contract.

The Contractor shall be responsible for maintaining satisfactory standards of competence, conduct, appearance and integrity. The quality of work performance of the Contractor shall be subject to review.

The Contractor shall be familiar and Knowledgeable of the "Privacy Act of 1996", the Health Insurance Portability and Accountability Act "HIPAA", and the use of confidential information as an integral part of the everyday duties. The privacy of individuals must be protected to the fullest extent possible.

Coding Entry:

The Contractor Point of Contact, POC, will initiate and validate that each contract coder completed the Indian Health Service, IHS, background check process prior to a contract coder being assigned to an IHS facility.

The Contractor POC will ensure there is a brief orientation conducted as a new contract coder begins coding at an IHS facility for the purpose of ensuring that facility specific coding practices are incorporated into the contract coder's actual performance.

The Contractor will ensure all contract coders are ICD-CM certified and are performing at the full level of their certification.

Contractor will perform comprehensive review of all written dictated and electronic clinical ambulatory visits and inpatient discharges to assure the presence and compliance as indicated by the treatment rendered and procedures performed; compliance with hospital policy, medico legal, medical necessity, CMS regulatory requirements and ICD-CM coding conventions.

Contractor will interpret and assign diagnostic and procedural codes utilizing the ICD-9/10 CM, CPT, and HCPCS coding books/resources. Contractor will review ambulatory visits to ensure the provider selected the correct Evaluation and Management (E&M) code notifying the provider through the notification menu if the wrong E&M code was selected or if the E&M code is missing. Contractor should check with the facility to know whether to apply HCPCS codes for supplies issued to patient. Code assignments will be data entered including other patient visit clinical information into the Resource Patient Management System (RPMS) using numerous data entry mnemonics and editing options.

Interprets documented medical information within a patients visit file to accurately select and assign descriptive ICD, CPT, and HCPCS diagnostic, procedural codes and modifiers if applicable by; abstracting information to reflect the treatment received identifying secondary complications and co-morbidity conditions, and sequencing codes following coding principles and conventions to accurately reflect services received by a patient.

Contractor identifies inconsistencies, discrepancies and/or trends within the medical record and formulates appropriate written queries to the appropriate medical, nursing, or healthcare providers and recommends appropriate modifications to include specificity/clarification of documentation, justification of medical necessity and adherence to correct coding policy under the Correct Coding Initiative (CCI), facility policy and regulatory requirements.

Complete visits files created by other clinical RPMS/EHR programs such as: Laboratory, radiology, immunization, and pharmacy programs by verifying dates of services location of services, taking appropriate steps to modify, merge, delete or create files to reflect accurate patient care visits.

Identify and verifies data is entered into the correct RPMS/EHR package and location i.e. dental, teen clinic, satellite clinic or school.

Enter of statistical information to include clinic and provider codes, visit time, location sites and level of patient services.

Verifies visit data within the IHS Electronic Health Record System (EHR) for completeness for the above identified elements and verify completed visits from the EHR coding queue for billing and statistical processing.

Contractor should be coding within 4 days of visit to maintain compliance with IHS Internal Control Policy.

Productivity: Contractors will code a minimum of 125 visits per 8-hour day, 8:00 AM to 4:30 PM with a 30-minute lunch break, 62.5 visits per 4-hour day and PRN work at 15.6 visits per hour in an outpatient setting. Inpatient contract coders will code a minimum of 16 inpatient records per day, 2 inpatient discharges per hour.

The Albuquerque Area IHS has adopted the RPMS/EHR as their legal health record therefore allowing for off-site remote coding. An onsite contract coder(s) may be requested by any Service Unit.

Contractors are responsible to make certain all annual information security agreements and background investigations are kept current, any concerns of lapsing will be brought to the attention of the Service Unit point of contact (POC).

Contractor POC will contact Service Unit POC weekly when performing coding duties to communicate any deficiencies or concerns.

Perform internal reviews to assure code assignments made by staff are in compliance with coding rules and compliance.