SOW-PINE RIDGE BUSINESS OFFICE.pdf

Pine Ridge Indian Health Hospital-Business Office Medical Claims Transmission & RemiƩance Service

Statement of Work

Scope of Work

Purpose:

It is mandated by IHS Headquarters that payment systems are updated to reflect changes in medical pracƟce and relaƟve value of services. Based on this, secure exchange managed services shall be uƟlized for the medical claims process to keep in compliance. The Pine Ridge Indian Health Service (IHS) Hospital of the Great Plains Area IHS requires a secure exchange data soŌware soluƟon to provide connecƟvity to Medicare systems and clearinghouse services.

AddiƟonally, eligibility verificaƟon services and the ability to perform third party insurance medical (inpaƟent, outpaƟent, day surgery and specialty clinic) claims validaƟon, approval and processing services for Medicare, Medicaid, VA and Commercial Payers for the Pine Ridge Service Unit shall be required.

These services shall be vital in providing confidenƟality, authenƟcaƟon, integrity and non-repudiaƟon for the Pine Ridge IHS Hospital and associated Health Centers located in South Dakota.

Statement of Work:

The contractor shall provide a secure exchange data soŌware soluƟon that provides technology for:

ConnecƟvity to Medicare electronic claims submission systems and real-Ɵme claim status inquiry capabiliƟes.

Eligibility verificaƟon for third party payers to include Medicare and Medicaid.

Third party insurance medical claims validaƟon, approval and processing services via a clearinghouse for Medicare, Medicaid, VA and Commercial Payers for the Pine Ridge Service Unit.

Ability to process all claim types: InpaƟent, OutpaƟent and Specialty Clinics.

The soŌware services shall comply with the following constraints:

The soŌware service shall not require Pine Ridge Service Unit faciliƟes to install contractor soŌware within the Pine Ridge IHS Hospital environment.

The service should enable Pine Ridge IHS faciliƟes to exchange data uƟlizing secure file transfer protocols as approved by the IHS Office of InformaƟon Technology.

The service shall support Electronic Data Interchange (EDI) transacƟons including X12 837, 835, 270, 271, 276, and 277 transacƟon sets.

The service shall support mulƟple users (20 maximum) and access shall be workstaƟon independent.

The service shall not entail development of Health Insurance Portability and Accountability Act (HIPAA) transacƟon set translaƟon or mapping processes for non-CMS or non-IHS generated data or messages, or data reformaƫng.

The service shall confirm and sign the informaƟon agreements to be established via an InterconnecƟon Security Agreement and Memorandum of Understanding between IHS and the Contractor.

The service shall also conform to a business associate agreement to be established between the Pine Ridge Service Unit and the Contractor.

The contractor shall support end-to-end communicaƟon tesƟng, implementaƟon and daily operaƟons of the data transfers from the contractor to the Pine Ridge Service Unit faciliƟes, which shall include, at a minimum:

The contractor shall provide rouƟne technical support to implement correcƟons to service occurring because of errors, flaws, or other failures within their service.

The contractor shall noƟfy the designated Pine Ridge IHS point of contact or ContracƟng Officer's RepresentaƟve (COR) of any scheduled maintenance that shall result in downƟme at least two (2) days prior to the maintenance period.

The contractor shall noƟfy the designated Pine Ridge IHS point of contact of any issues that result in the disrupƟon of data exchange capabiliƟes. This noƟficaƟon shall occur as soon as possible aŌer the disrupƟon has been idenƟfied.

The contractor shall provide customer support for reporƟng, documenƟng, tracking and resolving service problems, which shall be available via telephone and email to the Pine Ridge IHS technical staff during the period 8:00 am to 5:00 pm Mountain Standard Time on weekdays, except federal holidays.

The contractor shall provide:

Secure internet-based connecƟvity to all current Medicare AdministraƟve Contractors (MACs) and other payers.

Ability to send medical inpaƟent, outpaƟent, day surgery and specialty claims to Medicare contractors using secure data exchange technology.

Unlimited electronic Medicare claims submission and real-Ɵme claims status inquiry capabiliƟes for Medicare Part A and Part B.

All electronic transacƟons provide confidenƟality, authenƟcaƟon, integrity and non-repudiaƟon.

Automated batch 837/835 file transfers.

Automated batch 276/277 claims status inquiry and response capability.

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

Reports and acknowledgements on all claims sent.

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

Verify Medicare and Commercial Payer eligibility in real Ɵme using 270/271 transacƟons.

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 Mountain Standard Time, Monday through Friday, except federal holidays.

The Contractor shall provide a two (2) hour minimum response Ɵme from noƟficaƟon by IHS at no addiƟonal cost to the Pine Ridge IHS Hospital.

The medical claim processing services shall meet the following standards:

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

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

The Contractor shall use rouƟne ediƟng procedures to detect defects in medical claims informaƟon supplied by the government. The Contractor shall reject and not process all medical claims with defects. The Contractor shall provide the service locaƟon with edit status reports lisƟng the defect to aid IHS in the correcƟon of the detected defects.

The Contractor shall return to the appropriate IHS facility for correcƟon all claims rejected by all carriers/payers for any reason other than inappropriate format. 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 resubmiƫng the claims at the Contractor's expense.

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

The Contractor shall provide a producƟvity spreadsheet within 24 hours of batch transmission to be submiƩed to the originaƟng facility.

Contractor Compliance:

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

The Contractor shall maintain a record of confidenƟality in accordance with HIPAA, Privacy Act of 1974, 42 CFR Part 2 (ConfidenƟality of Substance Use Disorder PaƟent Records), Freedom of InformaƟon Act and other perƟnent Federal regulaƟons.

AdministraƟve:

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

MeeƟngs/Conference Calls: The Contractor shall aƩend meeƟngs or conference calls scheduled by the COR to address areas of concern and exchange informaƟon to ensure all contract requirements are met. The COR shall be responsible for scheduling and coordinaƟon of all meeƟngs and conference calls.

Equipment Failure: Any delays or downƟme 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 IHS equipment failure or updates that are beyond the Contractor's control (e.g., IHS server downƟme).

Reports:

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

a. Claim #

b. Date of Service

c. Total Amount Billed

d. Insurer Billed

e. Date Billed

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

a. PaƟent name

b. Claim #

c. Date of service

d. Total Amount Billed

e. Date TransmiƩed

f. Type of transmission (electronic)

g. Insurance carrier

h. Total # claims submiƩed

i. Total # claims accepted

j. Total # claims rejected

k. Rejected claim reasons (per claim)

Period of Performance:

One Year

Point of Contract

Rhonda Akers, Health System Specialist

Rhonda.akers@ihs.gov

Sara Lout, ContracƟng Officer RepresentaƟve

Sara.lout@ihs.gov