UMR - compressed.pdf

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State of Nebraska Dept. of Correctional Services | Corporate Overview

I. SOLICITATION RESPONSE INSTRUCTIONS

This section documents the requirements that should be met by bidders in preparing the Corporate Overview, Technical Response, and Cost Sheet. Bidders should identify the subdivisions of “Project Description and Scope of Work” clearly in their solicitation response; failure to do so may result in disqualification. Failure to respond to a specific requirement may be the basis for elimination from consideration during the State’s comparative evaluation.

Solicitation responses are due by the opening date and time shown in the Schedule of Events. Content requirements for the Corporate Overview, Technical Response, and Cost Sheet are presented separately in the following subdivisions: format and order:

A. SOLICITATION RESPONSE SUBMISSION

1. CORPORATE OVERVIEW

The Corporate Overview section of the solicitation response should consist of the following subdivisions:

a. BIDDER IDENTIFICATION AND INFORMATION

The bidder should provide the full company or corporate name, address of the company's headquarters, entity organization (corporation, partnership, proprietorship), state in which the bidder is incorporated or otherwise organized to do business, year in which the bidder first organized to do business and whether the name and form of organization has changed since first organized.

UMR, Inc.

115 W. Wausau Ave.

Wausau, WI 54401-2875

Toll-Free: (866) 881-0800

Website: umr.com

UMR is the third-party administrator (TPA) line of business for UnitedHealthcare, a business unit of UnitedHealth Group. UnitedHealth Group is a diversified health and well-being company dedicated to making health care work better. Headquartered in Minnetonka, Minnesota, UnitedHealth Group offers a broad spectrum of products and services. Through its family of businesses, UnitedHealth Group serves 147 million individuals worldwide.

UMR's state of incorporation is Delaware.

UMR was formed in 2008 by integrating three market-leading TPAs with a combined history in the health care industry dating back as far as 1948.

The history of UMR and its predecessor companies includes several names/name changes:

■ UMR in May 2008

■ Fiserv Health in January 2006

■ United Medical Resources in 2005

■ Midwest Security Administrators in 2002

■ Wausau Benefits in June 2000

b. FINANCIAL STATEMENTS The bidder should provide financial statements applicable to the firm. If publicly held, the bidder should provide a copy of the corporation's most recent audited financial reports and statements, and the name, address, and telephone number of the fiscally responsible representative of the bidder’s financial or banking organization.

If the bidder is not a publicly held corporation, either the reports and statements required of a publicly held corporation, or a description of the organization, including size, longevity, client

January 2025 Page 2 base, areas of specialization and expertise, and any other pertinent information, should be submitted in such a manner that solicitation evaluators may reasonably formulate a determination about the stability and financial strength of the organization. Additionally, a non-publicly held firm should provide a banking reference.

The bidder must disclose any and all judgments, pending or expected litigation, or other real or potential financial reversals, which might materially affect the viability or stability of the organization, or state that no such condition is known to exist.

The State may elect to use a third party to conduct credit checks as part of the corporate overview evaluation.

Please refer to UnitedHealth Group’s most recent Form 10-K found at: https://www.unitedhealthgroup.com/Investors/financial-reports.html.

From time to time, UMR is named as a defendant in various civil matters during the ordinary course of business. None of such lawsuits, either individually or in the aggregate, have at any time, even if the outcome were to be unfavorable to UMR, been of such a nature to impact UMR operations, or our financial situation, materially or adversely. We are unable to disclose further information and related details, as they are deemed confidential.

c. CHANGE OF OWNERSHIP If any change in ownership or control of the company is anticipated during the twelve (12) months following the solicitation response due date, the bidder should describe the circumstances of such change and indicate when the change will likely occur. Any change of ownership to an awarded bidder(s) will require notification to the State.

At this time, there are no pending agreements to sell UMR or merge with another organization.

d. OFFICE LOCATION The bidder’s office location responsible for performance pursuant to an award of a contract with the State of Nebraska should be identified.

Based on geography, time zone, plan complexity and plan type, we are proposing our Wausau, Wisconsin, service team.

e. RELATIONSHIPS WITH THE STATE The bidder should describe any dealings with the State over the previous three (3) years. If the organization, its predecessor, or any Party named in the bidder’s solicitation response has contracted with the State, the bidder should identify the contract number(s) and/or any other information available to identify such contract(s). If no such contracts exist, so declare.

Not applicable.

f. BIDDER’S EMPLOYEE RELATIONS TO STATE If any Party named in the bidder’s solicitation response is or was an employee of the State within the past six (6) months, identify the individual(s) by name, State agency with whom employed, job title or position held with the State, and separation date. If no such relationship exists or has existed, so declare.

If any employee of any agency of the State of Nebraska is employed by the bidder or is a subcontractor to the bidder, as of the due date for solicitation response submission, identify all such persons by name, position held with the bidder, and position held with the State (including job title and agency). Describe the responsibilities of such persons within the proposing organization. If, after review of this information by the State, it is determined that a conflict of https://www.unitedhealthgroup.com/Investors/financial-reports.html

January 2025 Page 3 interest exists or may exist, the bidder may be disqualified from further consideration in this solicitation. If no such relationship exists, so declare.

g. CONTRACT PERFORMANCE If the bidder or any proposed subcontractor has had a contract terminated for default during the past three (3) years, all such instances must be described as required below. Termination for default is defined as a notice to stop performance delivery due to the bidder’s non-performance or poor performance, and the issue was either not litigated due to inaction on the part of the bidder or litigated and such litigation determined the bidder to be in default.

It is mandatory that the bidder submit full details of all termination for default experienced during the past three (3) years, including the other Party's name, address, and telephone number. The response to this section must present the bidder’s position on the matter. The State will evaluate the facts and will score the bidder’s solicitation response accordingly. If no such termination for default has been experienced by the bidder in the past three (3) years, so declare.

If at any time during the past three (3) years, the bidder has had a contract terminated for convenience, non-performance, non-allocation of funds, or any other reason, describe fully all circumstances surrounding such termination, including the name and address of the other contracting Party.

h. SUMMARY OF BIDDER’S CORPORATE EXPERIENCE The bidder should provide a summary matrix listing the bidder’s previous projects similar to this Solicitation in size, scope, and complexity. The State will use no more than three (3) narrative project descriptions submitted by the bidder during its evaluation of the solicitation response.

The bidder should address the following:

i. Provide narrative descriptions to highlight the similarities between the bidder’s experience and this Solicitation. These descriptions should include:

a) The time period of the project,

b) The scheduled and actual completion dates,

c) The bidder’s responsibilities,

d) For reference purposes, a customer name (including the name of a contact person, a current telephone number, a facsimile number, and e-mail address);

and

e) Each project description should identify whether the work was performed as the prime Vendor or as a subcontractor. If a bidder performed as the prime Vendor, the description should provide the originally scheduled completion date and budget, as well as the actual (or currently planned) completion date and actual (or currently planned) budget.

ii. Bidder and Subcontractor(s) experience should be listed separately. Narrative descriptions submitted for Subcontractors should be specifically identified as subcontractor projects.

iii. If the work was performed as a subcontractor, the narrative description should identify the same information as requested for the bidders above. In addition, subcontractors should identify what share of contract costs, project responsibilities, and time period were performed as a subcontractor.

January 2025 Page 4

UMR currently does not have a similar customer narrative to provide.

i. SUMMARY OF BIDDER’S PROPOSED PERSONNEL/MANAGEMENT APPROACH The bidder should present a detailed description of its proposed approach to the management of the project.

The bidder should identify the specific professionals who will work on the State’s project if their company is awarded the contract resulting from this Solicitation. The names and titles of the team proposed for assignment to the State project should be identified in full, with a description of the team leadership, interface, and support functions, and reporting relationships. The primary work assigned to each person should also be identified.

The bidder should provide resumes for all personnel proposed by the bidder to work on the project. The State will consider the resumes as a key indicator of the bidder’s understanding of the skill mixes required to carry out the requirements of the Solicitation in addition to assessing the experience of specific individuals.

Resumes should not be longer than three (3) pages. Resumes should include, at a minimum, academic background and degrees, professional certifications, understanding of the process, and at least three (3) references (name, address, and telephone number) who can attest to the competence and skill level of the individual. Any changes in proposed personnel shall only be implemented after written approval from the State.

UMR has an experienced staff of strategic client executives (SCEs) located throughout the country. Our goal is to always maintain a local presence in the service of our customers, where possible. UMR SCEs average 12 years of experience in various facets of the health insurance industry. Your SCE will be assigned based on various factors such as proximity to your location, group size and current workloads.

UMR will appoint a designated SCE to NDCS upon being named a finalist.

j. SUBCONTRACTORS If the bidder intends to subcontract any part of its performance hereunder, the bidder should provide:

i. name, address, and telephone number of the subcontractor(s),

ii. specific tasks for each subcontractor(s),

iii. percentage of performance hours intended for each subcontract; and

iv. total percentage of subcontractor(s) performance hours.

UMR is your single source third-party administrator. We provide most of our core services directly or through the UnitedHealth Group family of companies. This allows us to offer affordable solutions through integrated data elements and systems, streamlined implementations and unified account management support.

While most services are performed in-house or through sister companies, there are times when we partner with external vendors for certain services. We have programs in place to assure that these subcontractors meet relevant performance, operational, contractual/compliance and regulatory standards. In general, subcontractors are selected based on the strategic needs of our entire organization and dependent on the subcontractors’ abilities to comply with our requirements.

REVISED ATTACHMENT A, BIDDER QUESTIONNAIRE

RFP 120174 O3

Third-party administrator to process payments for claims/ invoices for an incarcerated individual(s) healthcare services.

Bidder Name: _UMR, Inc.__________________________________

It is preferred that the bidder uses this template. Bidder must describe in detail solutions on how their response meets and/or exceed the requirements as outlined in the RFP. Bidder should use the RESPONSE box below for the detailed solution being proposed.

If the bidder choses to provide additional documents outside this template to aid in their response, for evaluation purposes, bidder must cross-reference which question in Attachment A the supplemental documents support.

Business Requirements

C.1

No correspondence of any type is to be sent to the incarcerated individual(s). This includes, but is not limited to, explanation of benefits (EOB), checks, letters, brochures, billings, etc.

Describe what methods are in place to ensure that communication is not sent to the incarcerated individual directly.

RESPONSE:

Turning off all correspondence for members can be done with development.

C.2

Rates for Medical/Dental Claims submitted: Nebraska Medicaid Rates or the negotiated PPO.

Incarcerated Individuals and/or NDCS are not responsible for remaining balance due after Medicaid/PPO rates have been applied.

a. Contractor is responsible for notifying member providers on remittance statements.

No balance will be due after Medicaid or PPO rates are applied.

Rates for Medical/Dental Claims submitted: Nebraska Medicare Rates unless the negotiated PPO rate is lower. Incarcerated Individuals and/or NDCS are not responsible for remaining balance due after Medicare/PPO rates have been applied. Contractor is responsible for notifying member providers on remittance statements, no balance will be due after Medicare or PPO rates are applied.

Describe the process of how the contractor will notify member providers on remittance statements ensuring no balance will be due after Medicare Medicaid or PPO rates are applied.

RESPONSE:

Per Addendum Two (bidder Q&A responses) awarded bidders are permitted to pay provider claims in accordance with their contractor/provider agreement. UMR will be utilizing the UnitedHealthcare Choice Plus network. In accordance with our in-network provider contracts, balance billing is not permitted.

C.3 Bidder understands and acknowledges Nebraska Medicaid eligibility as defined by Nebraska Department of Health and Human Services (DHHS).

Will comply

Will not comply

Will comply. X

C.4 Bidder understands that deductible, coinsurance, and/or copays do not apply.

Will comply

Will not comply

C.5 Bidder understands that the awarded contractor will accept claims as timely if filed within two (2) years of date of service pursuant to the State Contract Claims Act, see Neb. Rev. Stat. § 81-8,306.

Will comply

Will not comply

C.6 Bidder understands Claims maximums such as day, dollar, and lifetime maximums do not apply.

Will comply

Will not comply

RESPONSE:

Will comply.

X

C.7 Bidder understands that preauthorization is not applicable for emergency services or inpatient services. For out-patient services, NDCS will provide a prior authorization number.

Will comply

Will not comply

UMR will administer prior authorizations as directed by NDCS. X

C.8

The services below should not be paid by contractor. Describe what processes will be in place to ensure these services are not paid.

a. Claims billed by out-of-network providers. These claims should be sent to NDCS for consideration.

b. Medications for use after leaving medical provider.

c. Prosthetics/ Orthotics except for those off-site items issued at the time of surgery.

i. Prosthetics/orthotics deemed necessary will need to be pre-approved by NDCS Medical

Director or designee and billed directly to NDCS.

d. Services covered by Medicaid.

e. Newborn or childcare.

f. Abortion.

g. Caffeine-related disorders.

h. Chiropractic care.

i. Dental implants.

j. Dentures/Dental Laboratory Services,

i. Claims deemed necessary will need to be pre-approved by NDCS Medical Director or designee and billed directly to NDCS.

k. Elective procedures.

l. Erectile dysfunction.

m. Factitious disorder.

n. Learning disorder.

o. Nicotine-related disorders.

p. Other conditions/disorders/issues/procedures as determined by the Medical Director or designee for NDCS Health Services.

RESPONSE:

We are able to code claims to automatically deny for services which are readily identifiable and are specifically excluded under the plan. We may not be able to code more complex claims involving multiple services and diagnoses to automatically deny. Complex details that cannot be coded to automatically deny will pend to the customer first representative (CFR) for review and determination. Wherever possible we code plans to automatically apply plan benefits and either pay or deny, as this improves efficiency and reduces the incidence of error. Our average plan automatic adjudication rate is 86.60%.

C.9

In-State and Out-of-State Services: Only those services approved by the NDCS should be submitted to contractor for payment. If billed, the following services should be paid by contractor:

a. Claims billed by out-of-network providers. These claims should be sent to NDCS for consideration.

b. Prosthetics/ Orthotics except for those off-site items issued at the time of surgery.

i. Prosthetics/orthotics deemed necessary will need to be pre-approved by NDCS Medical Director or designee and billed directly to NDCS.

c. Dentures/Dental Laboratory Services,

i. Claims deemed necessary will need to be pre-approved by NDCS Medical Director or designee and billed directly to NDCS.

Will comply. UMR will process claims according to the submitted plan design.

C.10 Bidder understands that Contractor will not pay Workers’ Compensation /Subrogation claims. The employer’s workers' compensation insurer must cover the incarcerated individuals for all work-related claims.

Will comply

Will not comply

RESPONSE:

NDCS can carve out subrogation and handle the process internally or through an external vendor. If you choose to do your own subrogation, all claims will be processed upon submission according to the plan. Claims will not be reviewed for subrogation identification. Our reporting team can create a report of paid claims which NDCS or their external vendor can use to identify claims with potential third-party liability and pursue accordingly.

X

C.11

Billing received for transplant services must be pre-approved by the NDCS Medical Director or designee. Patient must also meet transplant criteria. NDCS will not pay for elective transplant procedures.

Describe what processes will be in place to ensure that pre-approval is received prior to billing.

Not applicable. Prior authorizations services would be provided by NDCS.

C.12 Bidder understands Medicaid Claims are covered by Medicaid will not be paid by contractor. NDCS will notify contractor of any Medicaid service eligibility changes.

Will comply

Will not comply

RESPONSE:

NDCS will be responsible for communicating eligibility information to UMR in a timely manner. X

Bidder Requirements

E.7

Contractor network will include service providers for all NDCS facility locations.

Provide listing of in-network providers in a sortable file by each Specialty listed in Lincoln Physicians Directory in following 5 cities in Nebraska: Omaha metro area, Lincoln, York, Tecumseh, and McCook.

Will comply

Will not comply

Links to UnitedHealthcare Choice Plus provider directories are posted online at umr.com.

E.8

Describe the processes to ensure provider rates are not paid higher than the Nebraska Medicare rates.

Identify the processes to ensure provider rates are not paid higher than the Nebraska negotiated rates.

What reports are available that compare provider and Medicare Medicaid rates to the corresponding claims paid.

RESPONSE:

Not applicable. Per Addendum Two (bidder Q&A responses), awarded bidders are permitted to pay provider claims in accordance with their contractor/provider agreement.

E.9 Include an outline of compliance management for claims processing in accordance with the RFP Scope of Work.

Describe the proposed utilization management of claims process. Including the ability and process to customize the utilization management of claims.

RESPONSE:

Claims pass through our reimbursement policy editing software where they are reviewed for bundling/unbundling, duplication, exclusive services, modifiers, assistant surgeon, medical necessity of appropriateness of treatment and/or diagnosis, procedures and place of service, validation of age appropriateness and gender-specific procedures. If a claim edit is applied, additional review by our medical claim review (MCR) team is necessary.

E.11 Provide a list of all network providers with response to the RFP.

Links to UnitedHealthcare Choice Plus provider directories are posted online at umr.com.

Contractor Requirements – General

F.1.a Contractor’s network will include services for all NDCS facility locations Will comply

Will not comply

RESPONSE:

We are proposing our UnitedHealthcare Choice Plus network. Today, this network includes approximately seven out of every 10 available physicians and nine out of 10 hospitals nationwide. It currently consists of over 779,000 physicians and 6,000 hospitals. Customers will appreciate the vast reach of our network and the simplicity of one uniting administrative system.

F.1.b Describe how valid patient care claims for State incarcerated individual(s) committed to NDCS will be processed.

RESPONSE:

For paper claims, UMR has partnered with Exela Technologies for mail room and data entry processes.

Exela Technologies receives mail in their Salt Lake City, Utah, office where they open, sort, assign a claim control number (CCN) and scan claims. Exela Technologies handles our HCFAs based on the common Healthcare Procedure Coding System (HCPCS), dental and Universal Benefits (UB) claims. They send us data entered/repaired claims electronically.

For EDI claims (837), providers are able to submit claims electronically using the clearinghouse of their choice. All inbound clearinghouse claims are directed through Optum360 for delivery to UMR. A unique payer ID is provided.

If claims require certain manual interventions, they are sent to a claim processor to complete. Manual interventions may occur when a claim:

■ Pends during the front-end process, waiting for the claim information to be validated. This is prior to the claim being sent to a CFR for payment or denial.

■ Does not meet specific criteria (defined by business rules) and the claim must be entered into the system, field-by-field.

A claim processor works with a senior claim processor on any claim that requires investigation or further communication with the provider.

If a claim does not automatically adjudicate or does not need to be handled by a claims processor, it is sent to a CFR. The CFR reviews the claim and determines the appropriate action:

■ Pend for additional information

■ Pend to an internal support unit

■ Review for CARE program recommendations

■ Apply reasonable and customary (R&C)

■ Review for subrogation opportunities

■ Forward to the Prospective Fraud, Waste, and Abuse unit

■ Enter additional provider or process information that allows the claim system to determine eligibility, condition, provider and plan language requirements

After a claim has been processed through the system, our quality assurance team performs a quality review on approximately 2% of all claims. They verify claims were handled and processed according to plan benefits and processing guidelines.

F.1.c Describe how the contractor will ensure claims are paid properly and what measurements are in place to ensure Nebraska Medicare rates are do not exceed the negotiated rate.

RESPONSE:

Not applicable. Per Addendum Two (bidder Q&A responses), awarded bidders are permitted to pay provider claims in accordance with their contractor/provider agreement.

F.1.d Claims to be paid by Nebraska Medicaid are to be denied. Describe what methodology is used to ensure this requirement will be met.

RESPONSE:

Claims received by UMR are matched against plan and member information such as group number, name, DOB, and ID number, to ensure that the claim is for an eligible member. Claims for eligible members are then matched against eligibility information received by NDCS to confirm if the member has any other coverage such as Medicaid before the claim is sent for processing.

F.1.e Describe the ability to have the provider directory available via an electronic site. Including the process on how the directory is maintained by contractor to ensure accurate information.

RESPONSE:

Links to provider directories are posted online at umr.com. The directories are updated regularly (the frequency of updates varies based on the network).

Contractor Requirements - Reporting

F.2.a Contractor will provide NDCS Accounting with an automated denial report monthly (minimum).

Will comply

Will not comply

F.2.b

Provide an example of reporting that meets electronic reports requirements. Bidder may provide a narrative response expanding on reporting along with the samples.

Provide the following electronic reports, upon request by NDCS, at no charge:

Include a listing (title or topic) and provide a sample printout of all reports that are considered standard and included at no additional charge.

Special reports of health care paid for an incarcerated individual within two (2) business days.

Rejected claims and rationale for rejection.

Breakout by specialty, i.e. physical therapy, dental, psychiatry, maternity, etc.

Report of charges of $20,000 or above per incarcerated individual, per diagnosis, and per off-site hospitalization per occurrence, or as requested.

RESPONSE:

Please see below for information regarding our reporting.

InfoPort InfoPort, UMR’s proprietary data analysis and reporting tool, offers users a proactive strategy to pinpoint potential issues before they have a negative impact on results. With our dynamic reporting tool, NDCS will have the option to create, customize and schedule reports or run reports on demand. InfoPort’s flexibility offers a broad range of online reports that are accessible via a secure, password-protected website. With data available daily (lag of two business days), our reporting tool assists users with identifying emerging trends and reviewing alternative plan strategies.

The intuitive online reporting tool provides users with instant access to the following information:

■ Paid claims

■ Benefit utilization

■ Claim lag

■ Financial and plan cost activity

■ Network performance

■ Enrollment

■ Adult preventive service activity

■ Admission summary

■ Top claimant paid activity

With the option to review reports to identify emerging trends and alternative strategies, InfoPort empowers users to:

■ Monitor plan performance

■ View incurred but not reported (IBNR) activity based on incurred/paid claims

■ Identify trends and outliers by analyzing multiple years of UMR data (if available)

■ Identify high-cost patient activity based on a user-defined dollar threshold

■ Access transactional data

■ Drill down to details (protected health information (PHI) authorized users only)

■ Access various report designs

■ Customize report criteria, allowing a myriad of report variations

■ Save customized report templates

■ Schedule recurring reports with dynamic dates

■ Export to multiple formats such as Excel, PDF, Word and Rich Text

■ Provide access to report data in both PHI and non-PHI versions

Please refer to Exhibit A, InfoPort Report Sample.

F.2.c

Bidder should provide an example of reporting that meets these requirements. Bidder may provide a narrative response expanding on reporting along with the samples.

Contractor will provide a monthly listing in Excel format of all claims paid per incarcerated individual, identifying:

Incarcerated individual committed name.

NDCS Incarcerated individual identification number.

Incarcerated individual age/ date of birth.

Date of service (beginning and ending).

Medical provider name and location.

Place of service codes.

Detailed billing including ALL diagnosis code(s) and each procedure code(s) (ICD10, CPT, modifiers, units, and NDCS number(s)).

APR-DRG (Diagnose Related Group) + SOI (Severity of Illness) level determines reimbursement level.

Prospective Payment System detail showing weight and rate of each APR-DRG for different clinics/hospitals/surgical centers.

Total Gross charged amount.

Total Net paid amount.

Dates of claim submission to contractor.

Dates of payment to providers.

InfoPort is UMR’s proprietary data analysis and online secure reporting tool, providing authorized users with the option to create, customize by applying report data filters, schedule, and run on-demand reports. Report types include paid claims, benefit utilization, admission activity, financial activities, network performance, provider utilization, and enrollment activity. Data is updated daily with a lag of two business days.

F.2.d Provide an example of the Service Organizational Control Report (SOC2) and provide the Service Organizational Control Type 2 certification if applicable.

RESPONSE:

Please see below for information regarding Health Information Trust Alliance (HITRUST).

What is HITRUST?

HITRUST was founded in 2007 to help organizations effectively manage data, information risk and compliance.

HITRUST certification by the HITRUST Alliance enables vendors and covered entities to demonstrate compliance with HIPAA requirements based on a standardized framework. It provides an option for the health care sector to address information risk management across a matrix of third-party assurance assessments, with the hope of consolidating, reducing, and in some cases, eliminating the need for multiple reports.

What is HITRUST Common Security Framework Certification?

Organizations that create, access, store or exchange sensitive information can use the HITRUST Common Security Framework (CSF) assessment as a roadmap to data security and compliance. The CSF is a certifiable (by security assessors) standard that provides organizations with the needed structure, detail and clarity relating to information protection. It was designed as a risk-based approach to organizational security–as opposed to a compliance-based approach. The HITRUST CSF assurance program combines aspects from common security frameworks like ISO, NIST, PCI and HIPAA.

With input from leading organizations, HITRUST identified a subset of the HITRUST CSF control requirements that an organization must meet to be HITRUST CSF certified. After meeting the requirements on more than 160 controls that deal with software, security, privacy and other regulatory requirements, HITRUST concluded that UMR’s portal and support infrastructure meet the HITRUST CSF certification criteria.

Please refer to Exhibit B for a copy of UMR’s HITRUST certification.

Contractor Requirements – Electronic Dashboard

E.10

F.3.a

Provide an example of an electronic dashboard meeting the RFP requirements.

Describe what methodology will be used to establish an electronic dashboard meeting the minimum requirements as described in the RFP.

hboard must provide a minimum of the following.

Most expensive patients.

Top diagnoses.

Frequency of diagnoses.

Year to date.

Month to month.

Specialists/category.

Itemized billings for all patients.

Files be protected to meet confidentiality standards.

Prefer to have the capability to print off the file at NDCS.

Contractor shall provide menu listing of industry standard services including Certification and Concurrent

Review Requirements with applicable cost and bullet point Return on Investment (ROI) as options for NDCS to consider using:

Pre-payment auditing cost.

Concurrent review cost.

Complex medical review cost.

InfoPort is UMR’s proprietary data analysis and online secure reporting tool, providing authorized users with the option to create, customize by applying report data filters, schedule, and run on-demand reports. Report types include paid claims, benefit utilization, admission activity, financial activities, network performance, provider utilization, and enrollment activity. Data is updated daily with a lag of two business days.

F.3.b Contractor will, to the best of their abilities, include additional analytics on the electronic dashboard as required by the NDCS Medical Director. It is preferred that the data on the electronic dashboard be easily customized to perform analysis.

Will comply

Will not comply

RESPONSE:

If you require customized, ad hoc reports that are not included in our standard offering, we will be happy to discuss in further detail. Turnaround time for ad hoc reports is under 10 days after receipt of final data requirements. This time frame may be adjusted depending on the complexity of the request or if programming support is required. Ad hoc report data is requested through, and delivered to you via your assigned strategic client executive (SCE). Ad hoc reports are available in the following formats:

■ PDF

■ Microsoft Excel

■ Microsoft Excel Data-only

If a report cannot be produced by our ad hoc team, we will contact our IT department to discuss development options. Project timing and cost estimates are provided, and requirements discussed before beginning any work.

Contractor Requirements – Claims

F.4.a

When submitting claim inquiries to NDCS, contractor will provide details as described in the RFP.

Incarcerated individual committed name and date of birth.

NDCS five (5) or six (6) digits incarcerated individual identification number.

Medical provider name and location and clinic/hospital/surgical center if applicable.

Admit and Discharge Date.

Total Charges.

Detailed billing including ALL diagnosis code(s) and each procedure code(s) (ICD10, CPT, modifiers, units, and NDCS number(s)).

APR-DRG (Diagnose Related Group) + SOI (Severity of Illness) level determines reimbursement level.

Will comply

Will not comply

RESPONSE:

UMR can manually provide the above information to NDCS upon request if needed for a claim review decision.

Contractor Requirements –Meetings

F.5.a F.5.b Contractor will attend quarterly meetings and an annual review of SOC2. Will comply Will not comply

PAYMENT SCHEDULE/DELIVERABLES

J.1.a Invoices shall include detailed itemized billing per patient including ALL diagnosis code(s) and each procedure code(s) (ICD10, CPT, modifiers, units, and NDCS number(s)).

Will comply

Will not comply

J.2.a If awarded at a fee per incarcerated individual, the formula used to calculate the monthly processing fee shall be “fee per incarcerated individual multiplied by the ADP.”

Will comply

Will not comply

J.2.b If awarded at a monthly flat rate, no formula will be required on invoices. Will comply

Will not comply

Will not comply.

J.3 All recoupment requests to NDCS will be processed within 30 calendar days upon agreement.

Will comply

Will not comply

OPTIONAL SERVICES (NOT SCORED)

K.1

Prior to claims being paid, a utilization review shall be completed to include but is not limited to reviewing claims for appropriate services, review procedures/documentations related to visit for appropriateness and review hospital stays for appropriate length of stay.

Describe in detail the analytical capabilities and competency of providing a detailed, accurate and comprehensive utilization review.

RESPONSE:

Please see below for an overview of our Utilization Management program.

Ensuring Clinical Appropriateness One of the greatest challenges for health care organizations today is to provide high-quality, cost-effective treatment for patients. UMR CARE supports health care organizations, customers and members by providing effective utilization management services. We base our URAC-accredited Utilization Management program on three concepts:

■ Timely review and determination of medical necessity

■ Determination of appropriate inpatient length of stay

■ Identification of potential Complex Condition CARE or Ongoing Condition CARE referrals

Cost-Reducing Prior Authorization and Notification Services It is a fact that early intervention can often lead to claim cost reduction. We work closely with our customers to understand their culture and benefit plan objectives. We have a recommended list of inpatient and outpatient procedures for prior authorization review, and allow our customers to customize this list, based on their requirements. Through our prior authorization and advanced notification process, we work to ensure procedures are medically appropriate.

Hospital admissions generally follow a consistent treatment course without the need for aggressive utilization management. UMR, however, monitors all cases, from initial notification through discharge. Our goal is to ensure these cases do not deviate from the expected treatment plan and become complicated and costly. By monitoring each case, we can gain early awareness of a case’s financial implications. Cases that might be deemed high risk are forwarded to our Complex Condition CARE or Ongoing Condition CARE programs for further review. Triggers for analysis include ICD diagnosis codes, CPT procedure codes, length of stay criteria and claims dollar thresholds, as well as specific criteria requested by customers or stop loss carriers.

Thorough Inpatient Care Management and Concurrent Review Our inpatient CARE nurses conduct concurrent review to determine which setting is most appropriate for hospitalized members who require additional care. We also check to ensure the length of stay is appropriate and observed. Our inpatient CARE nurses help with discharge planning to support the member going to the appropriate lower level of care once they are medically stable and ready for discharge.

A UMR medical director oversees complex cases to determine the best course of action and consults with the member’s physician if necessary.

Transition Planning Transition planning begins as early as the notification process and/or at the time of admission. We offer discharge planning assistance upon admission or when we are notified of the admission. During a concurrent review, the Utilization Management nurse ensures that transition planning is in place for discharge. UMR’s goal is to intervene as early as possible to determine the resources needed to deliver quality clinical care at a reasonable expense.

K.2 Describe and/or provide examples of any other available analytical services, reports, quality assurance, auditing, tools etc., at no additional cost.

RESPONSE:

InfoPort is UMR’s proprietary data analysis and reporting tool, which provides users with an option to create and customize reports. InfoPort is highly flexible and offers a broad range of online reports that are accessible via a secure, password-protected web environment. Reports can be run on demand or scheduled by the authorized user to run weekly, monthly, quarterly or annually. Transactional data is updated daily with a lag of two business days. Authorized users have the option to drill down to details within InfoPort reports and export data using multiple formats such as Excel, PDF, Rich Text and Word.

We also offer the following no-charge report packages:

■ Plan activity and checkpoint evaluation – monthly

■ Plan performance and analytic review – yearly

Plan Activity and Checkpoint Evaluation Report The plan activity and checkpoint evaluation report is a comprehensive, PDF formatted, reporting package delivering data based on paid medical claims and eligibility activity administered by UMR during the customer’s plan year. This summary-level report includes an enrollment versus cost trend, network utilization, and paid claims utilization activity by place of service, with benchmarks using UMR book of business activity. The year-over-year comparison assists with identifying plan cost breakouts by high-cost versus non-high-cost claimants and the number of readmissions based on inpatient claims activity.

Plan Performance and Analytic Review Report The plan performance and analytic review report displays several data components including an executive summary of enrollment demographics, cost drivers, high cost claimant activity with top highest cost conditions, paid medical claims by on demand care and illness, acute clinical conditions paid, inpatient admissions, preventive screenings and well visits, emergency room service utilization, network performance, condition focused data, paid pharmacy claims (if available), UMR Clinical Advocacy Relationships to Empower (CARE) activity, and dental claims activity (if applicable) in a series of reports presented in a report package. A minimum of 12 months of incurred claims with three additional paid months of UMR medical claims data is required; two full years of data will provide a year-to-year comparison.

Plan performance and analytic review reporting is available in PDF or PowerPoint format and provided by the customer’s SCE as part of an annual customer meeting. The report contains year-over-year customer comparisons for a 24-month period (if data is available), including the most recent customer year evaluated to benchmarks derived from the UMR book of business. Key findings related to the metrics are highlighted and opportunities with recommendations for program improvement are identified to assist the customer with strategic plan management.

Internal Claim Auditing UMR has a group of dedicated individuals across multiple functions that serve as our Quality Alliance unit.

This unit is comprised of five separate audit teams that were established to specifically meet our service expectations and our customers’ needs.

■ Internal Claim Review: This team is responsible for the daily monitoring of processor quality on both an individual and customer basis. All automatically adjudicated claims in excess of $15,000 and manual claim payments in excess of $150,000 are reviewed for accuracy (unless a processor has a higher check limit).

UMR also has these quality measures in place:

■ Random Reviews: Each week a stratified random claim sampling is selected for review. These include both claims released by a CFR and automatically adjudicated claims. A quality auditor analyzes these claims for coding, payment and procedural accuracy. If the auditor detects an error, he or she provides feedback to the appropriate CFR who then corrects the error.

■ Special Case Reviews: Unit supervisors review claims that exceed specific dollar values (e.g., over-check limit and large-dollar claims) as well as those that involve payment to a third party (other than the employee or provider).

■ Targeted Reviews: For quality improvement purposes, UMR conducts reviews on a pre-check basis which are focused on particular claim scenarios.

■ Trainee Reviews: All trainee claims are reviewed on a pre-check basis until the CFR has reached an acceptable quality performance level.

■ Strategic Business Assessment: This team serves as a corporate audit department and performs comprehensive reviews of each business unit for total operational, security and claim controls. The team also performs corporate claim audits on behalf of a number of existing customers and detailed focused audits on all new customers as they transition to UMR. The goal is to mirror an external audit in a more comprehensive manner.

■ Ancillary Department Review: This team is responsible for reviews of ancillary departments, including enrollment, provider, flexible spending account (FSA) and data entry.

■ External and Regulatory Audit: This team is responsible for the coordination of all external customer audit requests and regulatory audits in addition to SSAE 18 (SSAE 16/SAS 70) facilitation. They also perform special audits to monitor compliance for PPACA and health care reform (HCR).

K.3 Describe any additional like-services that are available which are not specifically mentioned in this

RFP.

RESPONSE:

Our claims processing system was internally designed to meet the needs of a diverse customer base, as well as to accommodate changes in the benefits environment. It provides consistent administration for a wide variety of benefit plans and pricing arrangements. The system is flexible and is easily enhanced for new products and services.

This flexibility gives us the ability to administer all levels of fee schedules and PPO configurations. We can also administer conversion factor pricing, negotiated or fixed-fee schedules, provider discounts, reasonable and customary (R&C) fee administration, per diem rates or any combination of these elements.

Cost Proposal

Third-party administrator to process payments for claims/ invoices for an incarcerated individual(s) healthcare services.

Bidder Name: UMR, Inc.

All expenses associated with these services must be bid as all-inclusive. No other costs shall be billed. This is an estimated usage contract based on historical data and will fluctuate based on the average daily population (ADP). The bidder may use the ADP of 5872 and may refer to the historical information provided in the RFP to help aid in developing cost. This contract shall have no minimum/maximum ADP requirements.

The bidder shall provide two (2) cost solutions for the Medical and Dental payment processing fees. One (1) cost solution will be for a flat monthly rate and one (1) cost solution at a rate per incarcerated individual. The State will determine if the award will be based on the monthly flat rate or award at the rate per incarcerated individual, whichever is deemed in the best interest of the State.

1. Bidder shall:

a. Provide a monthly flat rate for both the Medical Payment Processing Fee and the Dental Payment Processing Fee.

2. Bidder shall:

a. Provide a rate per incarcerated individual for the Medical Payment Processing Fee and the Dental Payment Processing Fee.

i. For billing purposes, the formula used to calculate the processing fee shall be “fee per incarcerated individual multiplied by the average daily population”, the formula used shall be on every monthly invoice.

1. Example: “$19.50 (fee) x 5872 (ADP) = $114,504”.

Monthly flat rate Unit of Measure ADP Initial contract term cost per month Renewal 1 (Optional)

Renewal 2 (Optional)

Medical payment processing fee Per month 5872 Not applicable. Not applicable. Not applicable.

Dental payment processing fee Per month 5872 Not applicable. Not applicable. Not applicable.

Rate per incarcerated individual Unit of Measure ADP Initial contract term cost per individual Renewal 1 (Optional)

Renewal 2 (Optional)

Medical payment processing fee Per person 5872 $18.50 $18.95 $19.40

Dental payment processing fee Per person 5872 $1.22 $1.24 $1.27

Cost Proposal

Third-party administrator to process payments for claims/ invoices for an incarcerated individual(s) healthcare services.

Bidder Name: UMR, Inc.

3. OPTIONAL SERVICES, NOT REQUIRED.

a. NDCS may consider awarding optional services as outlined in section V.K. at the time of award or after contract award, if deemed in the best interest of the State.

b. If optional services are provided with the RFP response, the bidder must provide cost for optional services with the response.

c. Bidder may add additional rows if needed.

Description of Optional Service Unit of Measure

Initial contract term cost

Renewal 1 (Optional)

Renewal 2 (Optional)

Not applicable. Not applicable. Not applicable. Not applicable. Not applicable.

SPB Form 22 | RFP Template | Effective 07192024 i State of Nebraska Department of Correctional Services

REQUEST FOR PROPOSAL FOR SERVICES CONTRACT

SOLICITATION NUMBER RELEASE DATE

120174 O3 November 01, 2024

OPENING DATE AND TIME PROCUREMENT CONTACT

January 07, 2025, 2:00 p.m. Central Time Julie Schiltz

PLEASE READ CAREFULLY!

SCOPE OF SERVICE

The State of Nebraska (State), Department of Correctional Services, is issuing this solicitation for a service contract for the purpose of selecting a qualified bidder to process payments for claims/ invoices for an incarcerated individual(s) healthcare services on behalf of NDCS. A more detailed description can be found in Section V. The resulting contract may not be an exclusive contract as the State reserves the right to contract for the same or similar services from other sources now or in the future.

The term of the contract will be four (4) years commencing upon notice to proceed. The Contract includes the option to renew for two (2) additional two (2) year periods upon mutual agreement of the Parties. The State reserves the right to extend the period of this contract beyond the termination date when mutually agreeable to the Parties.

In the event that a contract with the awarded bidder(s) is cancelled or in the event that the State needs additional Vendors to supply the solicited services, this solicitation may be used to procure the solicited services up to twenty-four (24) months from the date the Intent to Award is posted, provided that 1) the solicited goods or services will be provided by a bidder (or a successive owner) who submitted a response pursuant to this solicitation, 2) the bidder’s solicitation response was evaluated, and 3) the bidder will honor the bidder’s original solicitation response, including the proposed cost, allowing for any price increases that would have otherwise been allowed if the bidder would have received the initial award.

ALL INFORMATION PERTINENT TO THIS SOLICITATION CAN BE FOUND ON THE INTERNET AT:

https://das.nebraska.gov/materiel/bidopps.html.

IMPORTANT NOTICE: Pursuant to Neb. Rev. Stat. § 84-602.04, State contracts in effect as of January 1, 2014, and contracts entered into thereafter, must be posted to a public website. The resulting contract, the Solicitation, and the awarded solicitation response will be posted to a public website managed by DAS, which can be found at http://statecontracts.nebraska.gov and…