SOW - OCAO Software Application and Clearinghouse Services.docx

Scope of Work

Purpose:

It shall be mandated by IHS Headquarters that payment systems are updated to reflect changes in medical practice and relative value of services. Based on this; secure exchange managed services shall be utilized for the medical claims process to keep in compliance. The Oklahoma City Area Indian Health Service requires a secure exchange data software solution to provide connectivity to the Medicare DDE (Direct Data Entry) /FISS (Fiscal Intermediary Standard System) products. Additionally, eligibility verification services and to ability to perform third party insurance medical (inpatient, outpatient, day surgery and specialty clinic) claims validation, approval and processing services for Medicare, Medicaid, VA and Commercial Payers for the Oklahoma City Area shall be required.

These services shall be vital in providing confidentiality, authentication, integrity and non-repudiation for eleven IHS facilities; Claremore Indian Hospital, Lawton Indian Hospital, Anadarko Indian Health Center, Carnegie Indian Health Center, Pawnee Indian Health Center, Clinton Indian Health Center, El Reno Indian Health Center, Watonga Indian Health Center, Wewoka Indian Health Center, Oklahoma City Area Office located in Oklahoma and the Haskell Indian Health Center located in Kansas.

Statement of Work:

The contractor shall provide a secure exchange data software solution that provides technology for:

· Connectivity to the Medicare DDE (Direct Data Entry) /FISS (Fiscal Intermediary Standard System) products.

· Eligibility verification for third party payers to include Medicare.

· Third party insurance medical claims validation, approval and processing services via a clearinghouse for Medicare, Medicaid, VA and Commercial Payers for the Oklahoma City Area (OCA).

· The contractor shall be able to process all claim types: Inpatient, Outpatient and Specialty Clinics.

The software services shall comply with the following constraints:

The software service shall not require OCA facilities to install contractor software within the Oklahoma City Area Indian Health Service Environment The service shall enable OCA facilities to exchange data utilizing a secure File Transfer protocol (FTP) as approved by the Indian Health Service (IHS) Office of Information Technology.

The service shall support Electronic Data Interchange (EDI) transactions and interactive Telnet application protocol sessions.

The service shall support multiple users (50 maximum) and access shall be workstation independent.

The service shall not entail development of HIPAA (Health Insurance Portability and Accountability Act) transaction set translation or mapping processes, non-CMS or non-IHS generated data or messages, or data reformatting The service shall conform and sign the information agreements to be established via an Interconnection Security Agreement and Memorandum of Understanding between Indian Health Service and the Contractor.

The service shall also conform to a business associate agreement to be established between the OCA facilities and the Contractor.

The contractor shall support end-to-end communication testing, implementation and daily operations of the data transfers from the contractor to the OCA facilities, which shall include, at a minimum:

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

The contractor shall notify a designated OCA point of contact (Contracting Officer’s Representative (COR)) of any scheduled maintenance that shall result in downtime at least two (2) days prior to the maintenance period.

The contractor shall notify a designated OCA point of contact of any issues as that result in a disruption of data exchange capabilities. This notification shall occur as soon as possible after the disruption has been identified.

The contractor shall provide customer support for reporting, documenting, tracking and resolving of service problems, which shall be available via telephone and email to the OCA technical staff during the period 8:00 am to 5:00 pm central standard time on weekdays, except government holidays.

The contractor shall provide:

Secure internet based connectivity to all current fiscal intermediaries.

Ability to send medical inpatient, outpatient, day surgery and specialty claims to Medicare Contractor using a secure date exchange technology.

Unlimited Direct Data Entry (DDE) and Professional Provider Telecommunications Network (PPTN) online Medicare claims status/corrections for Medicare Part A.

All electronic transactions DDE/FISS access provides confidentiality, authentication, integrity and non-repudiation Automated batch 837/835 file transfers.

Automated batch 276/277 claims correction capability.

Accept electronic claims from Resource Patient Management System (RPMS).

Reports and acknowledgements on all claims sent.

Provide a single secure electronic location to manage all electronic claims, including VA claims.

Verify Medicare and Commercial Payer eligibility in real time.

Provide knowledgeable support personnel to assist with any issues regarding the processing of the medical claims.

The Contractor shall provide toll free telephone/technical support during normal business hours, 8 am to 5 pm, Monday thru Friday, except Government holidays. The Contractor shall provide a two (2) hour minimum response time from notification by IHS at no additional cost to the Oklahoma City Area Indian Health Service.

The medical claim processing services shall meet the following standards:

Third party insurance medical claims shall be submitted to the appropriate carrier/payer via the Contractor provided clearinghouse by the close of the next business day after receipt from IHS.

Third party insurance medical claims shall be transmitted electronically to the appropriate carrier/payer.

The Contractor shall use routine editing procedures to detect defects in medical claims information supplied by the government. The Contractor shall reject and not process all medical claims with defects. The Contractor shall provide the service location with edit status reports listing the defect to aid the service location in the correction of the detected defects.

The Contractor shall return to the appropriate IHS facility for correction all claims rejected by the all carriers/payers for any reason other than the inappropriate format to the claims. The Contractor shall not charge for any claims rejected prior to the submission to any carrier/payer.

Errors in processing or submission of medical claims shall be limited to reprocessing or resubmitting the claims at the Contractor’s expense.

The Contractor shall provide the capability for medical claim errors to be corrected and resubmitted electronically and provide a report of rejected medical claims within 4 hours of batch submission.

The Contractor shall provide a productivity spreadsheet within 24 hours of batch transmission to be submitted to the originating facility.

Contractor Compliance:

The Contractor shall adhere to all official coding and billing rules as published by the American Hospital Association (AHA), Centers for Medicaid and Medicare Services (CMS) regulations and guidelines in order to ensure the highest levels of integrity compliance and ethics.

The Contractor shall maintain a record of confidentiality in accordance with the Health Insurance Portability and Accountability Act (HIPPA), Privacy Act of 1974, Alcohol and Drug Abuse Patient Records, Freedom of Information Act and other pertinent Federal regulations.

Administrative:

Billing: Billing will be at a fixed rate for all services.

Meetings/Conference Calls: The Contractor shall attend meetings or conference calls scheduled by the Contracting Officer’s Representative (COR) to address areas of concern and exchange information to ensure all contract requirements are being met. The COR shall be responsible for scheduling and coordination of all meetings and conference calls.

Equipment Failure: Any delays or downtime due to Contractor equipment failure shall be communicated to the COR or their designee within two hours via telephone. The Contractor shall not be penalized for delays due to our equipment failure or updates that are beyond the Contractor’s control. (e.g., IHS server downtime).

Reports:

Medical Claims Approval: The Contractor shall deliver a standardized report to each facility on a minimum of a weekly basis, which shall include at the minimum the following:

c. Total Amount Billed

Clearinghouse: The Contractor shall deliver a standardized report to each facility on a weekly basis, which includes at a minimum the following:

f. Type of transmission (paper/electronic)

Period of Performance:

One Year with 4 Option Years.