Statement of Work Oral Surgery...pdf

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Department of Human Services

Clarks Summit State Hospital

Statement of Work Oral Surgery Services

IFB Number: 6100066620

I. Objective

The Department of Human Services (“DHS”) requires a Contractor to provide consultation and oral surgical procedure services, upon request, for consumers residing at:

Clarks Summit State Hospital (“CSSH”) located at 1451 Hillside Drive, Clarks Summit, Pennsylvania 18411.

II. Background

The selected Contractor shall provide oral surgical services at the selected Contractor’s place of business using their own equipment and materials and shall have an office located within a 50-mile radius of the CSSH. The selected Contractor shall provide oral surgical services to include, but not be limited to, examinations and evaluation, diagnoses, medical treatments and procedures, and follow-up care examinations, as needed.

III. Term of Service

The term of this service will commence upon issuance of a purchase order to the selected

Contractor (“Effective Date”) and will expire one year after the Effective Date unless it is terminated earlier pursuant to the terms of the purchase order.

The parties may agree to renew the purchase order for up to four additional one-year renewal periods, upon the same terms and conditions as set forth in the purchase order. At the time of each renewal the parties may negotiate the unit price not to exceed a maximum of three percent over the unit price in effect at the time of each renewal. The term of this project may be further extended by the Commonwealth for up to three months upon the same terms and conditions where a continued need exists for the services of the selected

Contractor and there has been no termination under the terms of the purchase order.

IV. Scope of Work

1. The CSSH Dental Department shall request services from the selected Contractor for consumers at CSSH.

2. The selected Contractor shall provide the following oral surgery or restorative dental procedures:

A. Examination and Evaluation;

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B. Diagnosis;

C. Medical treatment and procedures necessary to treat medical diagnosis, which may include:

• Panoramic Ex-ray;

• Oral Exam;

• Surgical Extraction;

• Retained Root;

• Partial Bony Extraction;

• Full Bony Extraction;

• General Anesthesia first 30 Minutes;

• General Anesthesia additional 15 Minutes;

• Removal Torus;

• Alveoplasty;

• Biopsy; or

• Miscellaneous. (Any procedure not listed)

D. Follow-up care examinations, as needed.

V. Specific Requirements and Qualifications

1. The selected Contractor shall be Board Certified in the specialty of oral surgery and shall possess an unrestricted license to practice Dental Oral Surgery in the

Commonwealth of Pennsylvania.

The Selected Contractor shall maintain Dental Malpractice and Liability Insurance for the entire term of the Contract.

VI. Bid Requirements

1. Contractors’ electronic submission must include the following as attachments. Failure to submit these items when they are needed may result in the rejection of the

Contractor’s submission.

A. Proof of Board-Certified License;

B. Proof of Dental Malpractice and Liability Insurance;

C. Cost Submittal;

D. Signed Lobbying Certification Form; and

E. Workers Protection and Investment Certification

2. Failure to submit these items when they are needed may result in the rejection of the

Contractor’s submission

VII. Questions and Answers

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All questions regarding the IFB must be submitted via email to apietlukie@pa.gov address. All questions must be received by 10/05/2026 09:00am. Contractors should include the IFB bid number in the subject of the email.

All questions and answers are considered an addendum to the IFB. DHS will post answers by 009/28/2026 10:00am.

VIII. Award

Award will be made based on the lowest responsible and responsive bidder.

IX. Estimated Quantities

The quantities are estimated only and may increase or decrease dependent upon the needs of the department.

X. Contact Information

Clark Summit Facility Contract Monitor:

Dr. Christine Yu

Clarks Summit State Hospital

Telephone: 570-587-7157

E-Mail: cyu@pa.gov

XI. Billing

The selected Contractor shall direct bill ORAL SURGERY SERVICES to CSSH by strictly adhering to the following terms and order of payers.

A. Oral Surgery services provided to consumers who are dually eligible for

Medicare Part B and Medical Assistance will be directly billed in the following sequential order of payers as follows:

1. Medicare.

2. Supplemental Insurance (Medicare deductible/co-insurance only)

3. Medical Assistance (Medicare deductible/co-insurance only)

4. CSSH

B. Oral Surgery services provided to consumers who are eligible for Medicare Part

B and not eligible for Medical Assistance will be directly billed in the following sequential order of payers as follows:

1. Medicare mailto:cyu@pa.gov

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2. Supplemental Insurance (Medicare deductible/co-insurance only)

3. CSSH

C. Oral Surgery services provided to consumers who are eligible for Medical

Assistance, or any insurance coverage will be directly billed in the following sequential order of payers as follows:

1. Medicaid or Insurance carrier

2. Secondary Insurance if applicable

3. CSSH

D. Oral Surgery services provided to Consumers who are not eligible for any coverage will be directly billed to CSSH.

XII. Confirmation of Service

A Service Receipt will be used to verify that work has been completed.

A Service Receipt should be sent to:

DHS - Clarks Summit State Hospital

Attn: Accounting Dept.

1451 Hillside Drive

Clarks Summit, PA 18411

XIII. Payment Provisions:

The selected Contractor will be reimbursed only for commodities/services performed and accepted by the Commonwealth of Pennsylvania.

Failure to submit invoices in compliance with the following instructions will result in the invoices being returned to the contractor and will substantially delay processing of payments. The contractor shall be paid upon satisfactory delivery/completion of work performed and submission of an invoice on the contractor’s letterhead.

The invoice should contain at minimum the information listed on the sample invoice –

Supplier Sample Invoice can be found at:

http://www.dgsweb.state.pa.us/comod/CurrentForms/SampleSupplierInvoice.doc http://www.dgsweb.state.pa.us/comod/CurrentForms/SampleSupplierInvoice.doc