STATEMENT OF WORK - 75H70723Q00067.pdf

STATEMENT OF WORK

The contractor shall provide a proposal that details remote professional medical coding, billing and accounts receivable services with the following specifications:

• CODING

o The contractor will assign and sequence ICD-10 CM/CPT/HCPCS codes to diagnoses and procedures from documented information. Assures the final diagnosis and operative procedures as stated by the physician are valid and complete. Abstracts all necessary information from the electronic health record to identify secondary complications and co-morbid conditions.

o The contractor will select the correct principal diagnoses and operations/ procedures. When multiple diagnoses and procedures are listed, assures the surgical procedure is related to the proper diagnosis. Assures maximum allocation under the diagnostic related group (DRG), ambulatory patient group (APG), system properly sequencing diagnosis and procedures in order of severity of illness treated.

o The contractor will abstract all necessary information, assigning the appropriate evaluation and management (E&M) levels of service, assigning the correct CPT/HCPCS code that accurately describes each medically documented procedure.

o The contractor will abide by official coding conventions and rules established by the Centers of Medicare and Medicaid (CMS).

o The contractor will utilize the Coding Que to complete patient visits within the Electronic Health Record (EHR) with no errors.

o The contractor will enter data from the patient visit as needed into RPMS database with no errors.

o The contractor will code visits within four days from Date of Service.

o The contractor will report to the Supervisory Health System Specialist (HIM Manager) or Contracting Officer’s Representative (COR) o The contractor will complete the error reports are reviewed and corrected on a daily and or weekly basis.

o The contractor will complete the Incomplete Coding Report; review, research and correct weekly.

• CLAIMS PROCESSING

o The contractor will submit claims electronically or manually in a timely manner (not to exceed filing limit) for all payers (Medicare, Medicaid, PI, BMP, BCCP, WC, FMCRA, Non-Beneficiaries, etc.) or all outpatient visits and according to Internal Controls and department policies.

o The contractor will bill and submit claims within six business days from date of service.

o The contractor will assure claims are mailed or transmitted within one business day from approval and maintain a log and submit to Business Office Manager on a monthly basis.

o The contractor will move forward to 100% for all payers to submit claims electronically. Electronic transmits must be HIPAA (837) compliant.

o The contractor will complete billing by accessing information, via the third party billing package that was input during the registration, EHR and coding queue process.

o The contractor will assure claims are analyzed and the technician will maintain the total billing operation for third party programs and acts as an advocate for the Indian Health Service in the collection of alternate resources by abiding AAAHC, CMS, State, IHS regulations and standards that govern Business Office department policies.

o The contractor will assure proper signatures are obtained for the Medicare Secondary Payer and Assignments of Benefits.

o The contractor will process the claim and assure that payer information is accurate and sequenced appropriately to guarantee the bill is submitted to the proper payer and includes identifying when employment related or accident related visits would designate a different responsible payer source from the patient’s usual primary payer.

o The contractor will bill clinic type, visit type, bill type, proper mode of export, Release of Information, workman’s compensation or FMCRA (third party injury) information, and referring physician information will be verified, input and/or adjusted whenever necessary.

o The contractor will split claim when appropriate.

o The contractor will assure appropriate providers are indicated and verify and assign proper Revenue codes if necessary.

o The contractor will assure proper dates of service for ancillary services and the E/M services.

o The contractor will assure if an error prompt appears on a particular billing page, the error must be identified and handled appropriately.

o The contractor will chart/visits with identified deficiencies (flagging/tracking process) either in the coding, data entry or the billing process will be compiled or returned to service unit for clarification and/or corrections. After correction those claims will be re-submitted.

o The contractor will respond to third party requirements on post-payment reviews, exclusions, denials, appeals and submits secondary payer claims as appropriate.

o The contractor will maintain the Electronic Transmit Confirmation Reports, reconcile and errors are corrected on a daily basis and resubmitted if necessary.

o The contractor will maintain diagnosis follow-up procedure and working relationship with Medical Record Technician.

o The contractor will maintain handling of inquiries from third party payers and patients regarding claims and ensure they are addressed correctly and timely.

o The contractor will work and maintain a log for Flagged as Billable Listing on a daily basis and identify reasons for unbilled claims and submit to Business Office Manager on a monthly basis.

o The contractor will maintain confidentiality of medical records in accordance with the Privacy Act, HIPAA, AAAHC, IHS, and Albuquerque Service Unit manuals.

o The contractor will report possible Risk Management issues to the Albuquerque Compliance Officer when discovered.

o The contractor will close-out all sessions every day.

o The contractor will run and correct the Auto Sync Report weekly.

• POSTING

o The contractor will post all payments within 72 hours from the receipt of supporting documentation utilizing the RPMS A/R package. Maintain log which identifies the following; name of batch, date batch received, date batch posted, and comments.

o The contractor will assure HIPAA standard adjustment reason codes are used for all posting transactions.

o The contractor will post all zero pay claims.

o The contractor will attach all EOB’s to reflect the batch posted. Maintain on the shared file folder.

o The contractor will close-out all sessions every day.

• ACCOUNT REVIEW AND FOLLOW-UP

o The contractor will reconcile the account by posted payment, credits, and adjustments within 45 days from date of service.

o The contractor will contact insurer if claim paid incorrectly, rejected claim, denied, or outstanding claims not paid.

o The contractor will review the final adjudication process of open accounts for further review or appeals and submit to insurers following payer guidelines.

o The contractor will utilize the Debt Management process for insurers after 180 Days from DOS.

o The contractor will follow and comply with HIPAA i.e. Standardized Adjustment Categories, Medicare Reason Codes, and Claim Status Codes.

o The contractor will document all account activity, i.e. date, time, representation name, and action/remarks in RPMS Message field.

o The contractor will adjust claims as necessary, utilize the prompt to roll-over claims for secondary payer etc.

o The contractor will assure to work the Aged Summary Report (ASM) until all claims are resolved with payments or true adjustments to have all accounts current. Work FY17 to current year.

o The contractor will maintain the Aging Account to be under 20% or until all accounts is current.

o The contractor will close-out all sessions every day.

o The contractor will assure that all applicable forms are submitted and adequately reflect the services rendered.

o The contractor will maintain current documentation and files for all third party utilization review activities in appropriate files, binders, etc.

o The contractor will assure filing of all Explanation of Benefits (EOB’s) in chronological order and by payer electronically.

o The contractor will generate correspondence on appeals and denials.

o The contractor will communicate new billing requirements and any issues found on follow up with Patient Registration, visit coding or medical documentation with Business Office Manager and/or Health Information Management Manager.

o The contractor will 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.

o The contractor will set up EFT and 835 files.

• DELIVERABLES/REPORTING REQUIREMENTS

o The contractor will code visits within four days from DOS.

o Contractor will contact provider if visit is not complete to meet the four days.

o The contractor will address the PPPV and TXER report weekly and provide weekly report to ASU Business Office Manager.

o The contractor will bill all visits within 10 days from DOS.

o The contractor will contact facility Patient Registration daily should patient demographics need to be revised. If insurance needs to be added the contractor will contact facility Accounts Receivable staff member.

o The BMP and BCCP claims will be billed on a monthly basis for all claims within the month by the following week of the last day of the month. If visits are denied due to past timely filing or billing error, the contractor will reimburse those monies back to the service unit due to failure of not having the claim billed timely or correctly.

o The contractor will address all Medicaid and Medicare claims and complete within 30 days from DOS and PI and other Insurances will be addressed and completed within 60 days from DOS. Failure to do so will result in contractor reimbursing service unit for loss revenue.

o The contractor will be notified to backfill for the Accounts Receivable Posting/Review/Follow-within two weeks or sooner to staff being out of office. Failure to follow-up on aged claims will result in contractor reimbursing service unit for loss revenue.

• REPORTING REQUIREMENTS

o The contractor will provide a weekly deficiency report which is compiled to communicate to the service unit including specific deficiencies for a particular visit as well as to help demonstrate repeat occurrences of issues. This information can be used to identify problem areas and help develop resolutions to the problem.

o The contractor will participate on a weekly conference call with the Business Office Manager to review the deficiency report and resolve any other issues as needed.

o The contractor will contact the Business Office Manager if unable to work due to technical difficulties or unanticipated events, as soon as possible to in order to make necessary changes.

o The contractor will submit timecard with hours and staff names on a monthly basis to the Business Office Manager for certification that satisfactory services have been received in accordance with the Scope of Services of the contract.

o The contractor will conduct weekly or bi-weekly calls with the Albuquerque Indian Health Center staff via conference call.

o The contractor will respond to requested reports such as PHN billing, Billed/Collected Ratio, etc.

o The contractor will provide training as requested to Albuquerque Indian Health Center staff.