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Deliverable Number
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Commodity/Service Type
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Major Deliverable
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Method of Payment
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Healthcare provider specialist services
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2) Address System downtime as follows: a) Provide written notice of scheduled downtime to the Contra...
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Fixed Price - Lump Sum
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| Major Deliverable: 2) Address System downtime as follows: a) Provide written notice of scheduled downtime to the Contract Manager a minimum of 48 hours before the downtime. Schedule System downtime outside system availability hours to not compromise, or prevent critical business operations from functioning, unless agreed to in writing by the Department. b) Notify the Department within one hour of discovery that the System is down, when it was not scheduled to be, with an estimate of the amount of time the System will remain down. Ensure the notification contains detail on how the System has been impacted by the downtime. Provide hourly updates to the Contract Manager until the System is no longer down. c) Identify the cause of any unscheduled downtime and if any changes are needed to prevent future unscheduled downtime. Provide this information to the Contract Manager within 24 hours of the discovery of unscheduled downtime. d) Resolve and restore the System from unscheduled downtime caused by the failure of the system or the hardware that supports the system within 48 hours or as described in the Business Continuity-Disaster Recovery (BC-DR) plan, described below. |
| Deliverable Price: $0.00 |
| Non Price Justification: Price cannot be determined until the work has been completed |
| Performance Metrics: d) Notification of scheduled downtime must be provided no less than 48 hours prior to the scheduled downtime as specified. e) Notification must be provided within one hour of discovery of any unscheduled downtime as specified. f) Notification on the cause of any unscheduled downtime must be provided within 24 hours as specified. g) Unscheduled downtime must be resolved and services must be restored within 48 hours or as specified in the BC-DR plan. |
| Financial Consequences: 4) Failure to provide notification of scheduled downtime no less than 48 hours prior to each scheduled downtime as specified will result in a reduction of $36.00 from the monthly invoiced amount per hour less than 48 hours of notice provided for each scheduled downtime. 5) Failure to provide notification of unscheduled downtime after discovery as specified will result in a reduction of $36.00 from the monthly invoiced amount per occurrence. 6) Failure to notify the Department of unscheduled downtime as specified will result in a reduction of $36.00 from the monthly invoiced amount per occurrence.
7) Failure to restore services within 48 hours of unscheduled downtime as specified will result in a $36.00 per hour reduction in the monthly invoiced amount until services are restored. |
| Source Documentation Page Reference: 11 |
| Deliverable Number: |
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Healthcare provider specialist services
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1) Manage, operate, and maintain the System as follows:
a) Ensure the System is operational during t...
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Fixed Price - Lump Sum
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| Major Deliverable: 1) Manage, operate, and maintain the System as follows:
a) Ensure the System is operational during the System availability hours, except for Department approved, scheduled downtimes. b) Provide troubleshooting support for operations and maintenance issues which are considered routine System changes in order to keep the System operational and as directed by the Department. c) Manage System authorized user access, login, and password information. Respond to Department’s request for authorized user access or termination within one business day. d) Assist authorized users with access to the System, use of System functions, data entry questions, and System reporting capabilities. Department has adopted a train-the-trainer approach for training new Department employees, however, the Department may from time to time ask Provider for assistance in additional training. e) Provide ad hoc reports to the Contract Manager within 20 calendar days of a written request, unless the Department directs Provider to respond in less than 20 calendar days. f) Provide technical consultation to the Department about issues that affect or may affect operations under this contract or as directed by the Department. Complete assigned follow-up items, analyses, reports, meeting notes, or other relevant tasks as mutually agreed to by the parties. g) Maintain all existing System interfaces. Update existing interfaces as directed by the Department when changes to technology or legal requirements requires an update.
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| Deliverable Price: $0.00 |
| Non Price Justification: Price cannot be determined until the work has been completed |
| Performance Metrics: a) The System must be available and operational a minimum of 99.5 percent of the time during system availability hours, each month as specified. b) Ad hoc reports must be provided at the Department’s request as specified. c) Interfaces must be maintained and updated as specified. |
| Financial Consequences: 1) Failure to ensure that the System is available and operational 99.5 percent of the time each month during System availability hours as specified will result in a reduction of $145.00 from the monthly invoiced amount for each one percent point below the minimum. 2) Failure to provide ad hoc reports as specified will result in a reduction of $73.00 per day from the monthly invoiced until the requested report is provided. 3) Failure to maintain and update interfaces as specified will result in a reduction of $15.00 per day from the monthly invoiced amount for each interface not maintained or updated. |
| Source Documentation Page Reference: 10 |
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Healthcare provider specialist services
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3) Provide routine System changes as follows: a) Upgrade the hardware and software in order to opera...
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Fixed Price - Lump Sum
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| Major Deliverable: 3) Provide routine System changes as follows: a) Upgrade the hardware and software in order to operate and maintain the System to satisfy tasks within this contract. b) Begin changes within one business day of notice by the Department when the change requested is for an issue identified to protect Department funds, the security of the personal health information (PHI), or data integrity. c) Complete performance of the change within 10 business days or as mutually agreed to in writing by both parties. |
| Deliverable Price: $0.00 |
| Non Price Justification: Price cannot be determined until the work has been completed |
| Performance Metrics: h) Changes for an issue identified to protect Department funds, the security of PHI, or data integrity must begin within one business day of notice. i) Routine System changes must be completed within 10 business days as specified or as mutually agreed to in writing by both parties. |
| Financial Consequences: 8) Failure to begin changes for an issue identified to protect Department funds, the security of PHI, or data integrity within one business day as specified will result in a reduction of $36.00 per hour reduction in the monthly invoiced amount until the change has begun. 9) Failure to complete all routine system changes as specified will result in a reduction of $36.00 per day from the monthly invoiced amount until the change has been completed. |
| Source Documentation Page Reference: 12 |
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Healthcare provider specialist services
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4) Maintain manuals for the System as follows: a) Maintain written manuals documenting and describin...
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Fixed Price - Lump Sum
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| Major Deliverable: 4) Maintain manuals for the System as follows: a) Maintain written manuals documenting and describing all manual and automated system processes and procedures. Post the manuals in the System so they are available for authorized users. Provide the manual in paper form to the Department as directed by the Department. b) Review manuals once annually at a minimum. Make updates as necessary, or as directed by the Department, to ensure that content is up to date and current. Submit any updated materials to the Department for approval, prior to incorporating into the manual. Post updated material in the System and notify authorized users of its posting within five business days after receipt of approval from Department. |
| Deliverable Price: $0.00 |
| Non Price Justification: Price cannot be determined until the work has been completed |
| Performance Metrics: j) Written System manuals must be maintained in the System as specified. k) Written System manuals must be updated annually and posted in the System as specified. |
| Financial Consequences: 10) Failure to maintain System manuals as specified will result in a reduction of $73.00 from the monthly invoiced amount for each day the manuals are not maintained. 11) Failure to update and post System manuals as specified will result in a reduction of $73.00 from the monthly invoiced amount for each day the manuals are not updated and posted. |
| Source Documentation Page Reference: 12 |
| Deliverable Number: |
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Healthcare provider specialist services
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5) Maintain and follow a BC-DR plan for continued operations in the event of a disaster as follows: ...
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Fixed Price - Lump Sum
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| Major Deliverable: 5) Maintain and follow a BC-DR plan for continued operations in the event of a disaster as follows: a) Back up all data and files in the System daily in a protected off-site location. Designate a secondary backup location site to provide operations in the event the primary site becomes inoperable for more than 48 hours. Complete the transfer of all data to the secondary location and have the System operable within 5 days in the event of a natural disaster. b) Include the process to resolve and restore services after unscheduled downtime caused by systems failure in the BC-DR plan. c) Post the BC-DR plan online in the System and provide a copy to the Contract Manager annually. d) Conduct an annual review of the BC-DR plan and determine whether the BC-DR plan needs to be updated and if so, submit a draft of the updated plan to the Contract Manager for approval prior to incorporating any changes. Submit a copy of the updated plan to the Contract Manager within five business days after the changes are approved. e) Upon receipt of written notification from the Department that changes are required to the BC-DR during the contract year, make those changes in accordance with CMS Plan requirements. Submit a redline version of the draft with changes to the Contract Manager for review and approval within five business days of notification from the Contract Manager. Submit the updated plan to the Contract Manager within five business days after the Department has approved the change. f) Conduct all operations in accordance with the BC-DR plan in the event of a triggering disaster or System failure. |
| Deliverable Price: $0.00 |
| Non Price Justification: Price cannot be determined until the work has been completed |
| Performance Metrics: l) Backup site must provide operations in the event the primary site becomes inoperable for more than 48 hours or as specified in the BC-DR plan. m) The BC-DR plan must be reviewed and updated annually as specified. |
| Financial Consequences: 12) Failure to have the backup site to provide operations if the primary site is down as specified will result in a $145.00 per day reduction in the monthly invoiced amount that the backup site is not operational. 13) Failure to review or update the BC-DR plan as specified will result in a reduction of $145.00 per day from the monthly invoiced amount until the BC-DR plan is reviewed or updated. |
| Source Documentation Page Reference: 12 |
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Healthcare provider specialist services
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6) Maintain a call center to provide telephone assistance as follows: a) Ensure the call center has ...
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Fixed Price - Lump Sum
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| Major Deliverable: 6) Maintain a call center to provide telephone assistance as follows: a) Ensure the call center has human operators to answer calls during business hours. If an automated phone tree system is used, ensure that an option to bypass the phone tree to connect with a human operator is available during business hours. b) Answer telephone calls and provide verbal information and assistance with claims to health care providers, recipients, claim submitters, and the Department. c) Provide operators who speak both English and Spanish or provide an approved interpretation services provider. Ensure access to the call center for individuals who have difficulty speaking or understanding the English language because that person’s native language is a language other than English. d) Respond to all verbal inquiries at the time of the call. Respond in writing within five business days of the call when an immediate verbal response is not possible. Use a call-tracking system to record the date, time, operator, subject, and answers given to each call. e) Ensure that a caller will not be placed on hold for more than an average of two minutes without a response by a human operator to the caller’s inquiry. f) Provide sufficient voicemail message capability to handle all incoming messages received outside of business hours. Return all calls by the end of next business day. g) Maintain and review statistics showing the reasons for calls, and initiate enhancements to reduce the number, duration, and manual processing time for calls through better automation, or training. h) Prepare a monthly report of all verbal calls and voicemail messages received. Submit the report to the Contract Manager within 30 calendar days following the end of each month. i) Provide an emergency call number that is answered immediately 24 hours per day, seven days per week, every day of the year. |
| Deliverable Price: $0.00 |
| Non Price Justification: Price cannot be determined until the work has been completed |
| Performance Metrics: n) Telephone calls must be answered by human operators during business hours as specified. o) An average of 95 percent of incoming calls must be answered as specified each day as computed monthly. p) A report of all calls and voicemail messages received must be prepared and submitted as specified. |
| Financial Consequences: 14) Failure to answer calls with human operators during business hours as specified will result in a $73.00 reduction in the monthly invoiced amount for each hour that calls are not answered. 15) Failure to answer a minimum of 95 percent of incoming monthly calls as specified will result in a reduction of $145.00 from that month’s invoiced amount for each percent point under the minimum. 16) Failure to submit a report on all calls and voicemail messages received as specified will result in a reduction of $36.00 from that month’s monthly invoiced amount and an additional $15.00 per day until the report is submitted. |
| Source Documentation Page Reference: 13 |
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Healthcare provider specialist services
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7) Ensure that all recipients in the system for purposes of claims payments are assigned a unique id...
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Fixed Price - Lump Sum
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| Major Deliverable: 7) Ensure that all recipients in the system for purposes of claims payments are assigned a unique identification (ID) across multiple programs and different time periods. Ensure that at a minimum the method includes, performing a record search to determine that a record does not already exist for a recipient for CMS services, and manually scanning similar records before adding a new record and before issuing a new ID. |
| Deliverable Price: $0.00 |
| Non Price Justification: Price cannot be determined until the work has been completed |
| Performance Metrics: n/a |
| Financial Consequences: 17) Failure to verify recipient’s eligibility in accordance with the medical criteria screening tool as specified in will result in a reduction of $145.00 from the monthly invoiced amount for each occurrence. |
| Source Documentation Page Reference: 14 |
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Healthcare provider specialist services
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8) Register, maintain, and update accurate and complete electronic data and associated data for heal...
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Fixed Price - Lump Sum
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| Major Deliverable: 8) Register, maintain, and update accurate and complete electronic data and associated data for health care providers as follows: a) Maintain current health care provider information required to perform claims processing and process payments. Perform updates as necessary, or as directed by the Department, and automatically update claims processing information. b) Load new health care providers into the System and incorporate the accurate and complete electronic data received from the Department and any vendors authorized to submit accurate and complete electronic provider records by the Department, to the System a minimum of once a week. Submit a file load report to the Contract Manager within 30 calendar days following the end of each month, showing this information. c) Return all incomplete or inaccurate records to the Department with a description of the reason the record could not be loaded into the System. d) Provide a health care provider load report upon request from the Contract Manager that list, at a minimum: health care providers by type, specialty, network affiliation, and group affiliation. Include health care provider payments made for any week, month, quarter, fiscal year or calendar year in the load report. e) Ensure a health care provider network verification file, in the file layout specified by the Department, to the Contract Manager, can be provided through a report retrieval in the System or within 15 calendar days of a written request by the Department. |
| Deliverable Price: $0.00 |
| Non Price Justification: Price cannot be determined until the work has been completed |
| Performance Metrics: q) A health care provider file load report must be submitted as specified. r) A health care provider network verification file must be submitted within 15 calendar days as specified. |
| Financial Consequences: 18) Failure to submit the health care provider file load report as specified will result in a reduction of $145.00 of the monthly invoiced amount for each day the report is not provided. 19) Failure to provide the health care provider network verification file within 15 calendar days as specified will result in a reduction of $145.00 from the monthly invoiced amount for each day the file is not provided. |
| Source Documentation Page Reference: 14 |
| Deliverable Number: |
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Healthcare provider specialist services
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9) Provide the ability for service authorization information for recipients to be entered into the S...
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Fixed Price - Lump Sum
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| Major Deliverable: 9) Provide the ability for service authorization information for recipients to be entered into the System by the Department as follows: a) Receive and store service authorization data needed for: (1) Requests, approvals, denials, partial approvals (some requested services but not others), designation of proposed funding source, and editing of requests; and,
(2) Process authorizations of non-medical services that may be paid by invoice under exceptional claim processing rules, or may be paid by the Department and accounted for in the System. b) Assign a unique transaction control number to each service authorization, identifying the date and transaction type. c) Track, identify, and display online the location of each authorization request, the individual authorized to make a decision regarding approval or denial, and the length of time the review has been pending. d) Employ a workflow management system to ensure that the Department is able to review service authorization requests within 72 business hours. e) Prepare a service authorization report tracking the timing of service authorizations. Ensure the report is available for the Department and delegated entities within 30 calendar days following the end of each month. f) Participate as directed by the Department in any internal or external quality improvement, utilization review, peer review, or grievance procedures established by the Department as specified in Attachment I, Section VIII.B.3.c.(3) of the AHCA Prime Contract. |
| Deliverable Price: $0.00 |
| Non Price Justification: Price cannot be determined until the work has been completed |
| Performance Metrics: s) The System must store service authorization data as specified. t) The Department’s ability to review service authorization requests in the workflow management system within 72 business hours must be ensured. u) A service authorization report must be submitted monthly as specified. |
| Financial Consequences: 20) Failure of the System to store service authorization entered into the System as specified will result in a reduction of $145.00 from the payment amount for each instance. 21) Failure to ensure the System allows the Department’s ability to review service authorizations in workflow management system as specified will result in a reduction of $145.00 from the monthly invoiced amount for each review that could not be completed within 72 business hours. 22) Failure to submit the service authorization report to the Department’s delegated entity as specified will result in a reduction of the monthly invoiced amount of $145.00 for each day the report is not submitted as specified. |
| Source Documentation Page Reference: 15 |
| Deliverable Number: |
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Healthcare provider specialist services
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10) Process claims for payment as follows: a) Comply with payment processing rules, funding rules, c...
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Fixed Price - Lump Sum
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| Major Deliverable: 10) Process claims for payment as follows: a) Comply with payment processing rules, funding rules, claims editing rules, and hierarchies based on CMS Plan requirements when conducting all services related to payments. Ensure accurate payment, denial, and coordination of benefits among all programs and payers. b) Use a National Provider Identification number (NPI) to identify health care providers. Use an alternative identification method for service providers who do not qualify to receive an NPI by not meeting the definition of “health care provider” pursuant to 45 CFR 160.103. Reconcile all health care provider identifiers assigned by Provider to match them to other payers’ health care provider identifier numbers, at all times during the claims payment process. Submit a reconciliation report of all health care providers assigned an identifier by Provider for purposes of reconciliation to the Contract Manager within 15 calendar days of written request by the Department. c) Institute payment processing steps that exercise separation of duties for Provider’s employees handling the claims, to ensure that no one individual may issue any payment. d) Return to the sender all paper claims that cannot be processed, because they are inaccurate due to missing, incomplete, or incorrect data, to the sender within five business days of receipt.
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| Deliverable Price: $0.00 |
| Non Price Justification: Price cannot be determined until the work has been completed |
| Performance Metrics: v) Paper claims that cannot be processed must be returned to the sender within five business days as specified. |
| Financial Consequences: 23) Failure to return a paper claim that cannot be processed within five days as specified will result in a reduction of $145.00 from the monthly invoiced amount for each day the claim is not returned. |
| Source Documentation Page Reference: 16 |
| Deliverable Number: |
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Healthcare provider specialist services
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e) Manage allowed contract rates for services pursuant to CMS Plan Requirements as follows: (1) Main...
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Fixed Price - Lump Sum
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| Major Deliverable: e) Manage allowed contract rates for services pursuant to CMS Plan Requirements as follows: (1) Maintain multiple rates based on date spans, by health care provider network, recipient enrollment category, and individual health care provider. (2) Make changes to rates as directed by the Department within 20 business days. (3) Reprocess all claims that are directly impacted as a result of rate changes and effective dates in accordance with the Medicaid Fee Schedule within 30 calendar days of the actual change to the rates within the System. (4) Use electronic data interchange (EDI) protocols to receive and transmit information necessary to process claims accurately and in agreed time frames. f) Create and maintain a record of the history of all claims submitted, including information translated or posted to the claim as part of editing, auditing, suspending, or adjudication of the claim. Maintain the original information and the translated or converted information, used to process the claim if translation or conversion is applied. g) Create and maintain a lifetime history file to record services that may be restricted over the course of a recipient’s lifetime, unless a specific issue exists that prevents this lifetime history file from occurring, e.g., adoption. h) Create and maintain 10 years of claims history including the ability to edit against the most recent three years of history for any claim or adjustment transaction processed. |
| Deliverable Price: $0.00 |
| Non Price Justification: Price cannot be determined until the work has been completed |
| Performance Metrics: w) EDI protocols must be used to receive and transmit information as specified. |
| Financial Consequences: 24) Failure to use EDI protocols to send and receive information as specified will result in a reduction of $73.00 from the monthly invoiced amount for each occurrence. |
| Source Documentation Page Reference: 16 |
| Deliverable Number: |
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Healthcare provider specialist services
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i) For all electronically submitted claims for services, adhere to the following timeframes for proc...
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Fixed Price - Lump Sum
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| Major Deliverable: i) For all electronically submitted claims for services, adhere to the following timeframes for processing: (1) Acknowledge receipt of all claims within one business day after receipt of the claim; (2) For nursing facility and hospice clean claims, pay the claim or notify the health care provider or designee that the claim is denied or contested within 10 calendar days of receipt; (3) For non-nursing facility or non-hospice clean claims, pay the claim or notify the health care provider or designee that the claim is denied or contested within 15 calendar days after receipt; (4) Include an itemized list of additional information or documents necessary to process a contested claim, in the notification to the health care provider or designee of a contested claim; and, (5) Pay or deny all claims that were initially denied or contested, within 90 calendar days after receipt. Comply with the timeframes set forth in section 641.3155, Florida Statutes (within 120 days after receipt of the claim) to avoid the claim being deemed uncontestable. j) For non-electronically submitted claims for services, adhere to the following timeline to processing: (1) Acknowledge receipt of the claim to the health care provider or designee, or provide the health care provider or designee with electronic access to the status of a submitted claim within 15 calendar days after receipt of the claim. |
| Deliverable Price: $0.00 |
| Non Price Justification: Price cannot be determined until the work has been completed |
| Performance Metrics: x) Electronically submitted claims must be acknowledged back to the health care service provider within one business day as specified. y) Electronically submitted nursing facility and hospice clean claims must be processed within 10 calendar days as specified. z) Electronically submitted non- nursing facility and non-hospice clean claims must be processed within 15 calendar days as specified. aa) All electronically submitted claims that were initially denied or contested, must be paid or denied as specified. bb) Non-electronically submitted claims must be acknowledged or electronic access must be provided within 15 calendar days as specified. |
| Financial Consequences: 25) Failure to acknowledge electronically submitted claims within one business day will result in a reduction of $145.00 from the monthly invoiced amount for each day the claim is not acknowledged as specified. 26) Failure to process electronically submitted nursing facility or hospice claims within 10 calendar days as specified will result in a reduction of $36.00 from the monthly invoiced amount for each day the claim is not processed. 27) Failure to process electronically submitted non-nursing facility or hospice clean claims within 15 calendar days as specified will result in a reduction of $145.00 from the monthly invoiced amount for each day the claim is not processed as specified. 28) Failure to pay or deny all electronically submitted clean claims that were initially denied or contested, within 90 days as specified will result in the reduction of $145.00 from the monthly invoiced amount for each day each claim is not paid or denied. Additionally, pursuant to section 641.3155(3)(e), Florida Statutes, failure to pay or deny all electronically submitted claims that were initially denied or contested, within 120 days, as specified will result in the reduction of the monthly invoiced amount in the amount of those claims the Department is required to pay on the claim due to Provider’s failure to pay or deny. The reduction in payment for each claim not paid as specified will not exceed $1,450.00. 29) Failure to acknowledge non-electronically submitted claims within 15 days as specified will result in a reduction of $145.00 from the monthly invoiced amount for each day the claim is not acknowledged. |
| Source Documentation Page Reference: 17 |
| Deliverable Number: |
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Healthcare provider specialist services
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(2) Within 20 calendar days after receipt of the claim, pay the claim or notify the health care prov...
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Fixed Price - Lump Sum
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| Major Deliverable: (2) Within 20 calendar days after receipt of the claim, pay the claim or notify the health care provider or designee that the claim is denied or contested. If the claim is contested, include an itemized list of additional information or documents necessary to process the claim and the time frames for submittal, in the notification to the health care provider. (3) Pay or deny all contested claims within 120 calendar days after receipt of the claim. Comply with the timeframes set forth in section 641.3155, Florida Statutes (pay or deny within 140 days after receipt), to avoid the claim being deemed uncontestable. k) Adhere to the following average claims processing times across all funding sources, regardless of the type or how submitted: (1) Pay or deny 50 percent of all submitted clean claims within seven business days; (2) Pay or deny 70 percent of all submitted clean claims submitted within 10 calendar days; and (3) Pay or deny 90 percent of all submitted clean claims within 20 calendar days. |
| Deliverable Price: $0.00 |
| Non Price Justification: Price cannot be determined until the work has been completed |
| Performance Metrics: cc) Non-electronically submitted claims must be paid, or notification that the claim is denied or contested must be provided within 20 calendar days as specified. dd) All non-electronically submitted contested claims must be paid or denied as specified. ee) A minimum of 50 percent of all submitted clean claims must be paid or denied within seven business days as specified. ff) A minimum of 70 percent of all submitted clean claims submitted must be paid or denied within 10 calendar days as specified. gg) A minimum of 90 percent of all submitted clean claims must be paid or denied within 20 calendar days as specified. |
| Financial Consequences: 30) Failure to pay or provide notification that non-electronically submitted claims have been denied or contested within 20 calendar days as specified will result in a reduction of $145.00 from the monthly invoiced amount for each day the claim is not processed. 31) Failure to pay or deny non-electronically submitted contested claims within 120 days as specified will result in a reduction of $145.00 from the monthly invoiced amount for each claim not paid or denied. Additionally, pursuant to section 641.3155(4)(e), Florida Statutes, failure to pay or deny all non-electronically submitted claims that were initially denied or contested, within 140 days, as specified will result in the reduction of the monthly invoiced amount in the amount of those claims the Department is required to pay on the claim due to Provider’s failure to pay or deny. The reduction in payment for each claim not paid or denied as specified will not exceed$1,450.00. 32) Failure to pay or deny a minimum of 50 percent of clean claims within 7calendar day as specified in this contract will result in a reduction of $145.00 from the monthly invoiced amount for each percentage point below the minimum. 33) Failure to pay or deny a minimum of 70 percent of clean claims within 10 calendar days as specified will result in a reduction of $145.00 from the monthly invoiced amount for each percentage point below the minimum. 34) Failure to pay or deny a minimum of 90 percent of clean claims within 20 calendar days as specified will result in a reduction of $145.00 from the monthly invoiced amount for each percentage point below the minimum. |
| Source Documentation Page Reference: 18 |
| Deliverable Number: |
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Healthcare provider specialist services
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11) Adjudicate disputed or contested claims by following all CMS requirements, including but not lim...
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Fixed Price - Lump Sum
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| Major Deliverable: 11) Adjudicate disputed or contested claims by following all CMS requirements, including but not limited to, applying complex logic rules, verifying paper forms and signatures, verifying invoices and charges, reviewing surgical or medical reports, reviewing photographs or models, and calculating or pricing procedures. a) Modify the claims adjudication process as necessary in order to remain in compliance with any updates to CMS Plan requirements or as directed by the Department. b) Resolve all disputed or contested claims within 20 business days following receipt of requested information unless the claim constitutes an appeal, which is the responsibility of the Department’s delegated designee. |
| Deliverable Price: $0.00 |
| Non Price Justification: Price cannot be determined until the work has been completed |
| Performance Metrics: hh) All disputed or contested claims must be resolved within 20 business days as specified. |
| Financial Consequences: 35) Failure to resolve all disputed or contested claims within 20 business days as specified will result in a $145.00 reduction from the monthly invoiced amount for each day a disputed or contested claim is not resolved as specified in this contract. |
| Source Documentation Page Reference: 18 |
| Deliverable Number: |
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Healthcare provider specialist services
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12) Cooperate with the Department’s auditors in a review of claims to determine payment accuracy in ...
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Fixed Price - Lump Sum
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| Major Deliverable: 12) Cooperate with the Department’s auditors in a review of claims to determine payment accuracy in accordance with section 641.3155, Florida Statutes, at the Department’s request, who will follow standard auditing practices and include claims with an original adjudication date within the term of this amendment. Ensure that the Provider’s payment error ratio is in accordance with section 641.3155, Florida Statutes. |
| Deliverable Price: $0.00 |
| Non Price Justification: Price cannot be determined until the work has been completed |
| Performance Metrics: ii) Adhere to the payment error ratio in accordance with section 641.3155, Florida Statutes as specified. |
| Financial Consequences: 36) Failure to adhere to the payment error ratio as specified in section 641.3155, Florida Statutes will result in a reduction of $36.00 from the monthly invoiced amount per claim in excess of that ratio. |
| Source Documentation Page Reference: 19 |
| Deliverable Number: |
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Healthcare provider specialist services
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13)Aggregate claims, make payments to health care providers, and report to the Department, on a week...
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Fixed Price - Lump Sum
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| Major Deliverable: 13)Aggregate claims, make payments to health care providers, and report to the Department, on a weekly basis unless otherwise noted, as follows: a)Aggregate payments based on tax identification number, and payee NPI, and line of business for each health care provider. Prepare a computer file and paper summary reports. b)Prepare a computer file of all paper check weekly payments and submit to the Department within two business days before the checks are scheduled to be mailed. c)Prepare an EFT Transmission File and submit it to the Department for approval. Transmit the file on a schedule where deposits to health care providers will arrive on a day directed by the Department. d) Prepare a weekly report of the payments made to a health care provider when that health care provider’s payment is more than 150 percent of its average payments over the three preceding months. Submit this report with the EFT and paper check file report. e)Remove any individual EFT payments from the EFT Transmission File as directed by the Department, and reverse any claims transactions, accounts payable or receivable or gross adjustments that constitute the removed EFT payment. f)Void any individual paper check when directed by the Department within one business day before the check mail date. Reverse any claims transactions, accounts payable, accounts receivable, or gross adjustments that constitute voided paper check the payment. g)Process and account for returned checks, refunds, subrogation payments, third party liability payments, and other amounts received using procedures approved by the Department. Withhold amounts from each weekly payment to address accounts receivable. h)Issue EFTs to all health care providers that have supplied the appropriate information to Provider, and that have EFT as their method of payment on file each week on Friday when it is a business day. If the Friday is not a business day, issue EFTs on the next business day or later, if directed by the Department. |
| Deliverable Price: $0.00 |
| Non Price Justification: Price cannot be determined until the work has been completed |
| Performance Metrics: jj) A computer file of all paper check weekly payments must be submitted as specified. kk) The EFT Transmission File must be prepared and submitted as specified. |
| Financial Consequences: 37) Failure to submit a computer file of all paper check weekly payments as specified will result in a reduction of $145.00 from the monthly invoiced amount for each day the file is not submitted. 38) Failure to prepare and submit the EFT Transmission File as specified will result in a reduction of $145.00 from the monthly invoice amount for each day the file is not prepared and submitted. |
| Source Documentation Page Reference: 19 |
| Deliverable Number: |
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Healthcare provider specialist services
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i) Print and mail paper checks to all health care providers that have paper checks as their selected...
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Fixed Price - Lump Sum
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| Major Deliverable: i) Print and mail paper checks to all health care providers that have paper checks as their selected method of payment on file each week on Friday. If the Friday is not a business day, print and mail paper checks on the next business day or later, if directed by the Department. j) Prepare a Remittance Advice which contains either an explanation of benefit payments or non-claims payment information, and that includes, but is not limited to, the recipient’s name, the date of service, the procedure code, service units, the amount of reimbursement and the identification of the health care provider for each check or EFT issued. Include the Remittance Advice with each printed paper check mailed. Post electronic versions of the Remittance Advice on a web portal with the payment cycle, for all health care providers requesting an electronic Remittance Advice. k) Recover funds that are paid in error and return any recovered funds to the Department, on an ongoing basis. l) Maintain a data record of all payments to health care providers and account balances, including net amounts payable to or receivable from health care providers. Prepare and submit, a report of this information to the Departments Contract Manager within 30 calendar days of the end of each month. m) Issue Internal Revenue Service (IRS) Form 1099 to all health care providers paid under this contract in the timeframe and threshold amounts specified by the IRS. n) Issue B-notices or other documents as required by the IRS. Process and apply any regular withholding formulas or amounts as required by the IRS. Submit a report of all submissions to the IRS. |
| Deliverable Price: $0.00 |
| Non Price Justification: Price cannot be determined until the work has been completed |
| Performance Metrics: ll) A report of the record of all payments to health care providers must be submitted as specified. |
| Financial Consequences: 39) Failure to submit a report of the record of all payments to health care providers within 30 days as specified will result in a reduction of $145.00 from the monthly invoiced amount for each day the report is not submitted. |
| Source Documentation Page Reference: 20 |
| Deliverable Number: |
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Healthcare provider specialist services
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o) Apply Coordination of Benefits rules when third party information is entered into the System by C...
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Fixed Price - Lump Sum
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| Major Deliverable: o) Apply Coordination of Benefits rules when third party information is entered into the System by CMS local office staff or other party payment is indicated on a received claim. Apply receipt of subrogation payments against previously paid claims to appropriately reflect CMS Plan responsibility. Recuperate funds paid by the Department, when Provider determines that a third party had the legal liability to pay for the services rendered under this contract. Recuperate funds paid by the Department, when the Department notifies Provider that a third party had the legal liability to pay for the services rendered under this contract. Create a report which shows active members with other insurance present on the member record and place within the System within 15 days of the end of each month. p) Create and maintain files necessary to generate capitation payments and management or administrative fees on the basis of per member per month for health care providers in certain networks as determined by Department. |
| Deliverable Price: $0.00 |
| Non Price Justification: Price cannot be determined until the work has been completed |
| Performance Metrics: mm) A report of any Coordination of Benefits discovered must be submitted as specified. |
| Financial Consequences: 40) Failure to submit the report on Coordination of Benefits as specified will result in a reduction of $36.00 from the monthly invoiced amount, and an additional $15.00 a day reduction until the report submitted. |
| Source Documentation Page Reference: 21 |
| Deliverable Number: |
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Healthcare provider specialist services
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14) Account for all funds processed through the System, or paid to Provider, for the administration ...
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Fixed Price - Lump Sum
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| Major Deliverable: 14) Account for all funds processed through the System, or paid to Provider, for the administration of this contract as follows: a) Ensure that all Department funds paid to healthcare providers under this contract are only paid out for the health care services authorized by the Department. b) Maintain the histories and updated balances for each funding source throughout the contract term. c) Adhere to Generally Accepted Accounting Principles (GAAP) and Generally Accepted Accounting Standards in all operations under this contract. d) Report financial control incidents and potential security or financial system breaches to the Department within one business day as Provider becomes aware of them. e) Balance the account upon receipt of the monthly bank statement. Submit a written summary of the bank account reconciliation to the Department within 30 calendar days of receipt of the electronic transaction file and statement from the bank. |
| Deliverable Price: $0.00 |
| Non Price Justification: Price cannot be determined until the work has been completed |
| Performance Metrics: nn) The history and updated amount must be maintained for each funding source as specified. |
| Financial Consequences: 41) Failure to maintain the history and balance for each funding source as specified, will result in a $145.00 reduction in the monthly invoiced amount for each day the history and updated balance for each funding source are not maintained. |
| Source Documentation Page Reference: 21 |
| Deliverable Number: |
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Healthcare provider specialist services
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15) Submit Encounter Data for Title XIX recipients as follows: a) Collect encounter data and prepare...
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Fixed Price - Lump Sum
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| Major Deliverable: 15) Submit Encounter Data for Title XIX recipients as follows: a) Collect encounter data and prepare in the standard HIPAA transaction formats, such as the ANSI X12 837 transaction formats (P-Professional; I-Institutional; D-Dental). Submit encounter data for all services rendered to recipients to AHCA’s fiscal agent in accordance with the requirements of Attachment I, Section VIII of the AHCA Prime Contract. b) Ensure encounters include the amounts paid by the Department to all health care providers (capitated and noncapitated). c) For claims that are adjudicated, submit encounters no later than seven days following the date of claim adjudication. d) Submit encounters for 95 percent of covered services provided by health care providers within seven calendar days from the end of the payment cycle. e) Ensure 95 percent of submitted encounters pass AHCA’s fiscal agent system edits as specified by the Department through AHCA. f) Remediate, correct, adjust, and reverse 100 percent of all failed encounters as required in order to pass AHCA’s fiscal agent system edits and resubmit to AHCA’s fiscal agent within 30 calendar days after notification that the encounters have failed unless the reason for the failure is beyond the span of control of the Provider. |
| Deliverable Price: $0.00 |
| Non Price Justification: Price cannot be determined until the work has been completed |
| Performance Metrics: oo) A written summary of the bank account reconciliation must be submitted as specified. pp) Encounter data for adjudicated claims must be submitted within seven days following the date of claim adjudication as specified. qq) Encounters for 95 percent of covered services must be submitted as specified. rr) One hundred percent of all failed encounters must be remediated, corrected, adjusted, and reversed as specified. |
| Financial Consequences: 42) Failure to submit a written summary of the bank account within 30 days will result in a reduction $73.00 per day from the monthly invoiced amount until the summary is submitted as specified. 43) Failure to submit encounter data within seven days after the date of claim adjudication as specified will result in a reduction of $73.00 from the payment amount for each day the encounter data is not submitted as specified. 44) Failure to submit encounters for 95 percent of covered services as specified will result in a reduction of $73.00 from the monthly invoiced amount for each percentage point below the minimum. 45) Failure to submit 100 percent of all failed encounters that have been remediated, corrected, adjusted and reversed as specified, unless the reason for the failure is beyond the span of control of the Provider, will result in a reduction of $73.00 from the monthly invoiced amount for each percentage point below the minimum. |
| Source Documentation Page Reference: 21 |
| Deliverable Number: |
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Healthcare provider specialist services
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15) Prevent fraud, waste, and abuse as follows: a) Maintain written policies and procedures designed...
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Fixed Price - Lump Sum
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| Major Deliverable: 15) Prevent fraud, waste, and abuse as follows: a) Maintain written policies and procedures designed to prevent, reduce, detect, and report known or suspected fraud and abuse activities as applicable and in accordance with sections 409.91212, 409.967(2), 626.989, and 641.3915, Florida Statutes, and specific information about section 6032, of the CMS Plan policies, the False Claim Act, the penalties for submitting false claims and statements, and the rights of employees to be protected as whistleblowers. b) Refer all suspected instances of internal and external fraud and abuse to the Department’s delegated entities, and the Contract Manager within five business days of detection. |
| Deliverable Price: $0.00 |
| Non Price Justification: Price cannot be determined until the work has been completed |
| Performance Metrics: ss) Written fraud and abuse policies and procedures must be maintained as specified. |
| Financial Consequences: 46) Failure to maintain written fraud and abuse policies and procedures as specified will result in a reduction of $73.00 per day from the monthly invoiced amount until fraud and abuse policies and procedures are maintained. |
| Source Documentation Page Reference: 22 |
| Deliverable Number: |
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Healthcare provider specialist services
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16) Ensure that a corporate audit of Provider’s financial statements is conducted a minimum of once ...
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Fixed Price - Lump Sum
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| Major Deliverable: 16) Ensure that a corporate audit of Provider’s financial statements is conducted a minimum of once each year of the contract, by an independent certified public accountant in accordance with GAAP. Submit a copy of this corporate audit within 90 calendar days following the business year end to the Contract Manager. |
| Deliverable Price: $0.00 |
| Non Price Justification: Price cannot be determined until the work has been completed |
| Performance Metrics: tt) A corporate audit of Provider’s financial statements must be performed by an independent certified public accountant and submitted as specified. |
| Financial Consequences: 47) Failure to perform and submit a corporate audit of Provider’s financial statements as specified will result in a reduction of $36.00 per day from the monthly invoiced amount until the audit is performed and submitted as. |
| Source Documentation Page Reference: 22 |
| Deliverable Number: |
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Healthcare provider specialist services
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17) Work in good faith with the Department to transition System data back to the Department. Provide...
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Fixed Price - Lump Sum
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| Major Deliverable: 17) Work in good faith with the Department to transition System data back to the Department. Provide predefined data extracts in accordance with the established turnover plan and associated change requests previously agreed to between the Department and Provider. Submit the data extracts to the Department on a quarterly basis, unless another date is agreed upon between the Department and Provider. |
| Deliverable Price: $0.00 |
| Non Price Justification: Price cannot be determined until the work has been completed |
| Performance Metrics: uu) The turnover plan must be adhered to as specified. |
| Financial Consequences: 48) Failure to adhere to the turnover plan as specified will result in a reduction of $145.00 per day from the monthly invoiced amount until the turnover plan is adhered to. |
| Source Documentation Page Reference: 23 |
| Deliverable Number: |
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Healthcare provider specialist services
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18) Submit monthly reports generated from the System within thirty calendar days following the end o...
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Fixed Price - Lump Sum
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| Major Deliverable: 18) Submit monthly reports generated from the System within thirty calendar days following the end of each month, demonstrating that each performance measure has been met in accordance with the specifications as stated for each corresponding financial consequence. |
| Deliverable Price: $0.00 |
| Non Price Justification: Price cannot be determined until the work has been completed |
| Performance Metrics: vv) The monthly reports demonstrating compliance with the required performance measures and standards in accordance with corresponding financial consequences must be submitted as specified. |
| Financial Consequences: 49) Failure to submit the monthly performance measure reports as specified will result in a reduction of $36.00 per day from the monthly invoices amount until the report is submitted. |
| Source Documentation Page Reference: 23 |
| Deliverable Number: |
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