Purchased/Referred Care Fiscal Intermediary Services
Sources Sought Notice: 75H70421R00019 IHS Purchased/Referred Care Fiscal Intermediary Services INTRODUCTION This is a Sources Sought Notice. This is NOT a solicitation for proposals, proposal abstract... Sources Sought Notice: 75H70421R00019 IHS Purchased/Referred Care Fiscal Intermediary Services INTRODUCTION This is a Sources Sought Notice. This is NOT a solicitation for proposals, proposal abstracts, or quotations. The purpose of this notice is to obtain information regarding the availability and capability of qualified Small Business concerns. Only small business concerns need to respond to this notice. BACKGROUND The Indian Health Service (IHS), an agency within the Department of Health and Human Services, is responsible for providing federal health services to American Indians and Alaska Natives (AI/AN). IHS provides a comprehensive health service delivery system for approximately 2.6 million AI/AN who belong to 574 federally recognized Tribes in 37 states. The Purchased/Referred Care (PRC) Program is an integral part of the IHS system. The IHS delivers care through direct care services provided in an IHS, Tribal or Urban Indian Health Program (I/T/U) facility and through PRC services delivered by non-IHS providers. The PRC Program allows Federal or Tribal facilities to purchase services from private health care providers in situations where: 1) no IHS or Tribal direct care facility exists; 2) the existing direct care element is incapable of providing required emergency and/or specialty care; 3) utilization in the direct care element exceeds existing staffing; and 4) supplementation of alternate resources (e.g., Medicare, Medicaid, or private insurance) is required to provide comprehensive health care to eligible AI/AN. The IHS requires a certified fiscal intermediary (FI) agent to provide a centralized medical and dental claims processing, reimbursement and reporting system for the PRC program. The IHS contracts for FI services under the authority contained in the Consolidated Omnibus Budget Reconciliation Act of 1985, Public Law 99-272, Section 17003 which “provides authority for the Secretary of the Department of Health and Human Services to contract with fiscal agents to perform claims payment, processing and audit functions with respect to services purchased on a contract basis by the Public Health Service … Fiscal Agents must either be entities which could qualify as carriers for Medicare purposes, or Indian Tribes or Tribal organizations acting under the Indian Self-Determination Act contracts. While the fiscal agents need not be Medicare carriers, they must meet the same requirements as Medicare carriers regarding efficiency and effectiveness of operations, surety bonds, and financial controls.” The FI enhances the overall administration of the PRC program by coordinating patient benefits, processing medical and dental claims, ensuring that IHS is the payer of last resort for services provided to patients and calculating payment rates in accordance with Medicare-Like Rates (MLR) and PRC Rates regulations and the IHS payment policy. The FI also provides IHS the capability to capture and retrieve data from a centralized database that is essential when responding to Congressional, General Accountability Office and Office of the Inspector General inquiries. The FI reports allows IHS managers at all levels to compare and make informed decisions about the types of services that the PRC program is purchasing. FI services are also made available to Tribes that assume PRC programs under the Indian Self-Determination Education and Assistance Act (P.L. 93-638). RESPONSE INFORMATION The capability statement must clearly demonstrate that a company has relevant experience; capacity, facility, personnel, and expertise in medical claims processing and benefits coordination; systems to support data collection and reporting; and capability to enable Tribal use of services. The capability statement shall demonstrate the offeror’s ability/capacity to work with 80 Federal and Tribal PRC programs and 15,000 healthcare providers to process 450,000 medical and dental claims annually worth nearly $1 billion. The offeror must demonstrate an understanding of the IHS mission, its health care delivery system and the purpose and function of the PRC Program. The offeror must be an entity that qualifies as a carrier for Medicare purposes or an Indian Tribe or Tribal organization acting under the Indian Self-Determination Act that meets the same requirements as a Medicare carrier for operations, bonds and financial controls. At a minimum, the capability statement shall demonstrate the offeror’s abilities and methodologies to provide the following services. A. Contractor’s qualification, capability and relevant experience in Medical Claims Processing, Benefit Coordination and Payments including specific information for: 1. Conducting voucher examination activities for medical and dental claims. 2. Coordination with providers and carriers for coverage information and payment calculation when conflicts occur. 3. Coordination with other payers for payer of last resort provision requirements. 4. Verifying authorizing authority for contracts, rate quote agreements and open market claims. 5. Issuing explanation of benefits reports for all claims even when alternate resources pay in full. 6. Processing claims in accordance with the applicable policies and the Prompt Payment Act, 31 U.S.C. 3901, et. seq, and its implementing policies and procedures. 7. Ensuring that all payments are made in accordance with Section 506 of the Medicare Modernization Act of 2003 and other applicable regulations, contracts or negotiated rate agreements. 8. Transition claims processing, reimbursements, and data collection from current vendor and provide the timeline to achieve full level of services. The submission shall include a six-month phase in plan and required phase out effort by the incumbent. 9. The offeror’s qualification and ability to extend FI services to Tribes operating PRC programs under the Indian Self-Determination and Education Assistance Act (ISDEAA), Public Law 93-638, as amended. 10. The Offeror’s capability to be in compliance with FAR 52.219-14 Limitations on Subcontracting, throughout the contract period. B. Contractor’s systems capability and interoperability including the following information: 1. Proven capability of the systems to support the scope with examples of the relevant usage. 2. The system’s capability to interface and operate with IHS systems to transmit payment and statistical data while fully meeting the Privacy Act and Health Insurance Portability and Accountability Act (HIPAA) requirements. INSTRUCTIONS TO INDUSTRY All capable parties are encouraged to respond. Responses must directly demonstrate the company’s capability, experience, and ability to marshal resources to effectively and efficiently perform the objectives described above. Generic capability statements are not sufficient and will not be considered compliant with the requirements of this notice. The Government requests interested parties submit a written response to this notice which includes: a. Company DUNS number and www.SAM.gov registration status. b. Company point of contact, telephone number(s), and website address c. Company’s relevant past performance information Disclaimer and Important Notes. This notice does not obligate the Government to award contract. Any information provided by industry to the Government as a result of this sources sought synopsis is strictly voluntary. Responses will not be returned. No entitlements to payment of direct or indirect costs or charges to the Government will arise as a result of contractor submission of responses, or the Government's use of such information or otherwise pay for the information provided in response. The Government reserves the right to use information provided by respondents for any purpose deemed necessary and legally appropriate. Any organization responding to this notice should ensure that its response is complete and sufficiently detailed to allow the Government to determine the organization’s qualifications to perform the work. Respondents are advised that the Government is under no obligation to acknowledge receipt of the information received or provide feedback to respondents with respect to any information submitted. After a review of the responses received, a pre-solicitation synopsis and solicitation may be published on a government GPE. However, responses to this notice will not be considered adequate responses to a solicitation. Confidentiality. No proprietary, classified, confidential, or sensitive information should be included in your response. The Government reserves the right to use any non-proprietary technical information in any resultant solicitation(s). Responses must be submitted via email, no later than 12:00 pm EST on June 16, 2021. Questions shall be submitted by 12:00 pm EST, June 7, 2021. Capability statements will not be returned and will not be accepted after the due date. The maximum number of pages for this submission is twenty (20) pages.
Data sourced from SAM.gov.
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