STATE OF MISSISSIPPI
STATE AND SCHOOL EMPLOYEES
HEALTH INSURANCE
MANAGEMENT BOARD
REQUEST FOR PROPOSAL FOR
THIRD PARTY MEDICAL CLAIMS
ADMINISTRATION SERVICES
December 20, 2010
TABLE OF CONTENTS
1
INTRODUCTION ........................................................................................................................ 5
1.1
1.2
1.3
1.4
1.5
1.6
1.7
1.8
1.9
1.10
1.11
1.12
1.13
1.14
1.15
1.16
1.17
1.18
1.19
OVERVIEW AND PROCESS ..................................................................................................................................... 5
INSTRUCTIONS TO PROPOSERS .............................................................................................................................. 7
IMPORTANT DATES: .............................................................................................................................................. 8
INTENT TO PROPOSE AND QUESTIONS ................................................................................................................... 8
STATEMENT OF COMPLIANCE REQUIREMENT ....................................................................................................... 9
STATUTORY REQUIREMENT .................................................................................................................................. 9
CORRECTIONS AND CLARIFICATIONS .................................................................................................................... 9
RIGHT OF NEGOTIATION........................................................................................................................................ 9
ACKNOWLEDGMENT OF RFP AMENDMENTS ....................................................................................................... 10
REPRESENTATION REGARDING CONTINGENT FEES ............................................................................................. 10
CERTIFICATION OF INDEPENDENT PRICE DETERMINATION ................................................................................. 10
REPRESENTATION REGARDING GRATUITIES ....................................................................................................... 10
DURATION OF PROPOSAL .................................................................................................................................... 10
WITHDRAWAL OF A PROPOSAL ........................................................................................................................... 10
COST OF PROPOSAL PREPARATION ...................................................................................................................... 11
PROPOSAL EVALUATION ..................................................................................................................................... 11
MISSISSIPPI PUBLIC RECORDS ACT/CONFIDENTIALITY OF PROPOSALS ............................................................... 13
RIGHT TO CONSIDER HISTORICAL INFORMATION ................................................................................................ 13
RIGHT TO REJECT, CANCEL AND/OR ISSUE ANOTHER RFP ................................................................................. 13
2
MINIMUM VENDOR REQUIREMENTS ............................................................................... 14
3
SCOPE OF SERVICES.............................................................................................................. 15
3.1
3.2
3.3
3.4
3.5
3.6
3.7
3.8
3.9
3.10
3.11
3.12
3.13
3.14
3.15
3.16
3.17
3.18
3.19
3.20
3.21
3.22
3.23
3.24
3.25
3.26
3.27
3.28
3.29
3.30
DEDICATED ACCOUNT SERVICE .......................................................................................................................... 15
EXCLUSIVE CUSTOMER SERVICE REPRESENTATIVE ............................................................................................ 15
STAFFING ............................................................................................................................................................ 15
COMMUNICATION MATERIALS/FORMS ............................................................................................................... 15
IDENTIFICATION (ID) CARDS .............................................................................................................................. 15
VENDOR SYSTEM INTERFACE.............................................................................................................................. 16
ON-LINE ACCESS FOR BOARD STAFF .................................................................................................................. 17
CLAIMS ADMINISTRATION .................................................................................................................................. 17
RUN-OUT CLAIMS ADMINISTRATION .................................................................................................................. 18
QUALITY CONTROL............................................................................................................................................. 18
PROVIDER CODING ACCURACY ........................................................................................................................... 18
HOSPITAL DRG VALIDATIONS AND BILL AUDITS ............................................................................................... 18
CREDIT BALANCE RECOVERY ............................................................................................................................. 18
PRICE NEGOTIATION ........................................................................................................................................... 19
ELIGIBILITY VERIFICATION ................................................................................................................................. 19
NATIONAL PROVIDER INDICATOR ....................................................................................................................... 19
NATIONAL DRUG CODES..................................................................................................................................... 19
PRE-EXISTING CONDITION DETERMINATIONS ..................................................................................................... 19
PRE-DETERMINATION OF BENEFITS .................................................................................................................... 19
PARTICIPANT AND PROVIDER CUSTOMER SERVICE ............................................................................................. 19
PROVIDER WEBSITE ............................................................................................................................................ 20
ELECTRONIC PAYMENT TO PROVIDERS ............................................................................................................... 20
ENROLLMENT AND ELIGIBILITY .......................................................................................................................... 20
PREMIUM BILLING AND ACCOUNT RECONCILIATION .......................................................................................... 23
PUBLIC EMPLOYEES’ RETIREMENT SYSTEM BILLING REPORT ............................................................................ 24
ELIGIBILITY FILES ............................................................................................................................................... 24
STORAGE AND RETRIEVAL OF ENROLLMENT FORMS .......................................................................................... 25
LIFE INSURANCE SUPPORT FUNCTIONS ............................................................................................................... 25
COBRA ADMINISTRATION ................................................................................................................................. 25
COORDINATION OF BENEFITS (COB) ADMINISTRATION ..................................................................................... 25
2010 State and School Employees Health Insurance Management Board TPA RFP
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3.31
3.32
3.33
3.34
3.35
3.36
3.37
3.38
3.39
3.40
3.41
3.42
3.43
3.44
3.45
3.46
3.47
3.48
3.49
3.50
3.51
4
SUBROGATION ADMINISTRATION (THIRD PARTY LIABILITY AND WORK-RELATED) .......................................... 26
OVERPAYMENT/RECOVERY ADMINISTRATION ................................................................................................... 26
MEDICARE SECONDARY PAYER (MSP) ............................................................................................................... 26
SATISFACTION SURVEY ....................................................................................................................................... 26
APPEAL AND GRIEVANCE PROCEDURES .............................................................................................................. 26
INDEPENDENT REVIEW ORGANIZATIONS ............................................................................................................ 27
MEDICAL DIRECTOR ........................................................................................................................................... 27
MEDICAL REVIEW DEPARTMENT ........................................................................................................................ 27
MEDICAL POLICY ................................................................................................................................................ 27
TRAINING PERSONNEL ........................................................................................................................................ 28
EXPLANATION OF BENEFITS ................................................................................................................................ 28
HIPAA EXEMPTION ............................................................................................................................................ 28
HIPAA COMPLIANCE.......................................................................................................................................... 28
CERTIFICATE OF CREDITABLE COVERAGE .......................................................................................................... 29
RETRIEVAL AND DISTRIBUTION OF RECORDS ..................................................................................................... 29
CLAIMS AND PERFORMANCE REVIEWS ............................................................................................................... 29
MEDICAL CONSULTATION ................................................................................................................................... 29
STANDARD/AD HOC REPORTING ........................................................................................................................ 29
BENEFIT FAIRS .................................................................................................................................................... 30
TRANSITION OF SERVICES ................................................................................................................................... 30
SAS 70 TYPE II AUDIT ........................................................................................................................................ 30
QUESTIONNAIRE .................................................................................................................... 31
4.1
4.2
4.3
4.4
4.5
4.6
4.7
4.8
4.9
4.10
4.11
4.12
4.13
4.14
4.15
4.16
4.17
4.18
4.19
GENERAL QUESTIONS .................................................................................................................................. 31
CUSTOMER SERVICE ..................................................................................................................................... 33
CLAIM PROCESSING ...................................................................................................................................... 35
PLAN DESIGN .................................................................................................................................................. 36
COORDINATION OF BENEFITS .................................................................................................................... 40
THIRD PARTY LIABILITY (WORKER'S COMPENSATION AND SUBROGATION) ............................... 41
NETWORK PROVIDER REIMBURSEMENTS .............................................................................................. 42
MEDICAL REVIEW AND APPEALS .............................................................................................................. 43
QUALITY ASSURANCE .................................................................................................................................. 44
EXPLANATION OF BENEFITS....................................................................................................................... 45
ELIGIBILITY AND PREMIUM BILLING ....................................................................................................... 46
SYSTEMS, DATA TRANSFER, AND REPORTING CAPABILITIES ........................................................... 49
CLIENT SERVICE ............................................................................................................................................ 52
BANKING ......................................................................................................................................................... 53
LEGAL AND LIABILITY ................................................................................................................................. 53
IMPLEMENTATION ........................................................................................................................................ 54
PERFORMANCE STANDARDS ...................................................................................................................... 55
REFERENCES ................................................................................................................................................... 55
FINANCIAL ...................................................................................................................................................... 56
5
FINANCIAL EXHIBIT ............................................................................................................. 57
6
STATUTORY REQUIREMENT............................................................................................... 58
7
STATEMENT OF COMPLIANCE AND DRAFT CONTRACT ............................................. 60
8
DRAFT THIRD PARTY MEDICAL CLAIMS ADMINISTRATION SERVICES
CONTRACT .............................................................................................................................. 62
Appendices:
Appendix A – Plan Enrollment
Appendix B – Plan Document
Appendix C – Performance Standards
2010 State and School Employees Health Insurance Management Board TPA RFP
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Appendix D – ID Card Layout
Appendix E – Vendor Interface Diagram
Appendix F – National Network Interface Diagram
Appendix G – SPHAHRS Hold File Layout
Appendix H – Electronic Enrollment Training Manual & Resolution Guide
Appendix I – Electronic Billing File Layout
Appendix J – Plan’s Current Enrollment Structure
Appendix K – PERS Billing Report File Layout
Appendix L – Insurance Procedure Manual
Appendix M – Required Standard Reports
Appendix N – Health & Wellness Guidelines
Appendix O – SPAHRS 834 File Layout
Appendix P – SPAHRS Confirmation File Layout
Appendix Q – SPAHRS Error File Layout
Appendix R – Data Management Vendor File Layout
Appendix S – Pharmacy Benefit Manager File Layout
Appendix T – Medical Management File Layout
Appendix U – Wellness and Health Promotion File Layout
Appendix V – Provider Network File Layout
Appendix W – Advanced Health System – National Network File Layout
2010 State and School Employees Health Insurance Management Board TPA RFP
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1
Introduction
1.1 Overview and Process
The State and School Employees Health Insurance Management Board of the State of
Mississippi (the Board) is seeking a vendor to provide comprehensive Third Party Medical
Claims Administration (TPA) services for the State and School Employees’ Health
Insurance Plan (Plan). The Department of Finance and Administration, Office of Insurance
(DFA) is responsible for the day-to-day operation of the Plan and is coordinating the request
for proposal (RFP) on behalf of the Board, with assistance from PricewaterhouseCoopers
LLP (PwC). Whenever “Board” is referenced, it shall mean the State and School
Employees Health Insurance Management Board and/or DFA unless the context clearly
indicates the contrary. The Board desires to contract with a qualified experienced TPA
capable of providing Third Party Medical Claims Administration Services as described in
Section 3 Scope of Services in this RFP as well as other services for which the TPA has the
technical capability to render.
The effective date of this contract will be January 1, 2012. The contract’s term will be four
(4) years with an option to renew for one (1) additional year, based solely at the Board’s
discretion. This contract shall be governed by the applicable provisions of the Mississippi
Personal Service Contract Review Board Regulations, a copy of which is available from the
Mississippi State Personnel Board located in the Robert G. Clark Jr. Building at 301 North
Lamar Street, Suite 100, Jackson, Mississippi 39201, or by accessing their website at
www.spb.state.ms.us.
A copy of this RFP, including any subsequent amendments, along with all vendor questions
and responses to those questions, will be posted on DFA’s website at www.dfa.state.ms.us
under the heading “Bid and RFP Notices”. Before the award of any contract, the proposer
will be required to document for the Board that it has the necessary abilities and financial
resources to provide all services specified in this RFP. The proposer may also be required
to provide additional client references, as well as related project experience detail, in order
to satisfy the Board that the proposer is qualified. The Board may make reasonable
investigations, as it deems necessary and proper, to determine the ability of the proposer to
perform the work and the proposer shall furnish to the Board all information requested for
this purpose. The Board reserves the right to reject any proposal if the proposer fails to
convince the Board that the proposer is properly qualified to carry out the obligations of the
contract and to complete the work described in this RFP.
The Plan, a non-grandfathered health insurance plan as defined by the federal Patient
Protection and Affordable Care Act of 2010 (PPACA), is a self-insured program currently
providing health insurance coverage to approximately 195,000 participants. Eligible
participants include active, retired, and COBRA employees (and their enrolled dependents)
of the State’s agencies, universities, community/junior colleges, school districts, and public
library systems. Plan participants are primarily located within the State of Mississippi,
although a small number of participants reside in other states. Refer to Appendix A of this
RFP for additional information on the Plan’s enrollment.
2010 State and School Employees Health Insurance Management Board TPA RFP
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The Plan offers two coverage choices for active employees, COBRA participants, and nonMedicare eligible retirees: Base Coverage and Select Coverage. Each coverage type is
independent of the other. The Plan also includes a separate coverage level for Medicare
eligible retirees, Medicare eligible surviving spouses, and Medicare eligible dependents of
retirees and surviving spouses. Detailed coverage level for Medicare eligible participants
can be found in the Plan Document located in Appendix B.
The Board currently contracts with Blue Cross & Blue Shield of Mississippi (BCBSMS) to
provide Third Party Medical Claims Administration Services. The Board’s contract with
BCBSMS expires on December 31, 2011, necessitating the issuance of this RFP.
The Board currently contracts with ActiveHealth Management (ActiveHealth), Inc. to
provide medical management and utilization review services for the Plan. Additional
services provided by ActiveHealth include medical case management, disease management,
clinical decision support, and pre and post discharge call services. Medical management
and utilization review services are described in detail in the Plan Document located in
Appendix B.
The Plan includes a separate retail and mail order co-payment program for prescription
drugs administered by a Catalyst Rx, the Board’s pharmacy benefit manager. The Plan’s
prescription drug program is described in detail in the Plan Document located in Appendix
B.
The Board contracts with Thomson Reuters to provide data management services. These
data management services provide the Board access to an integrated health care database
comprised of claims, provider, and eligibility data, as well as other health care data to
provide the capability of data analysis and to support decision making.
The Board contracts with Advanced Health Systems (AHS) to manage an exclusive network
of physicians, hospitals, and other health care providers. AHS is responsible for recruiting,
credentialing, and communicating with providers. Providers participating in the network
agree to accept the allowable charge fees set by the network and agree to file claims for Plan
participants. The Plan’s network is described in detail in the Plan Document located in
Appendix B. In addition, Advanced Health Systems contracts with a national network
provider. The TPA is responsible for the electronic transfer of non-network, out-of-state,
institutional claims to the national network for re-pricing. Once re-priced, these claims are
returned to the TPA for processing.
The Board contracts with WebMD Health Services to provide wellness and health
promotion services. Through this program, Plan participants complete a health risk
assessment and receive a personalized wellness plan and access to online lifestyle
improvement programs. The Plan’s wellness and health program is described in detail in
the Plan Document located in Appendix B.
The Board currently contracts for a fully insured group term life insurance policy with
Minnesota Life Insurance Company to provide a fully insured group term life insurance
policy for eligible employees and retirees of State agencies, universities, public libraries,
2010 State and School Employees Health Insurance Management Board TPA RFP
Page 6
and certain community/junior colleges and public school districts. Life insurance can be
continued when a covered employee retires or becomes totally disabled (as defined by the
life insurance company). The Plan’s term life insurance policy is described in detail in the
Plan Document located in Appendix B.
The Board’s TPA is required to cooperate with other Board vendors including, but not
limited to, those providing medical management administration, wellness and health
promotion services, pharmacy benefit management services, network administration, and
data management services.
1.2 Instructions to Proposers
Proposals must be submitted in writing with appropriate certification signatures as indicated.
Your proposal should be organized as follows:
a.
b.
c.
d.
e.
f.
g.
Introduction
Minimum Vendor Requirements Confirmation
Statement of Compliance
Statutory Requirement
Questionnaire/Responses
Financial Exhibit
Any Additional Information Not Specifically Requested
In preparing your written response to any RFP question or request for information, you are
required to repeat each question or requirement followed by your response.
Please provide complete answers and explain all issues in a concise, direct manner. If you
cannot provide a direct response for some reason (e.g., your company does not collect or
furnish certain information), please indicate the reason rather than providing general
information that fails to answer the question. “Will discuss” and “will consider” are not
appropriate answers. All information requested is considered important. If you have
additional information you would like to provide, include it as an attachment to your
proposal.
The Board will use the information contained in your proposal in determining whether you
will be selected for contract negotiations. The Board will consider the proposal an integral
part of the contract and will expect the proposer to honor all representations made in its
proposal.
It is the proposer’s sole responsibility to submit information relative to the evaluation of its
proposal. The Board is under no obligation to solicit such information if it is not included
with the proposer’s proposal. Failure of the proposer to submit such information in a
manner so that it is easily located and understood may have an adverse impact on the
evaluation of the proposer’s proposal.
All documentation submitted in response to this RFP and any subsequent requests for
information pertaining to this RFP shall become the property of the Board and will not be
returned to the proposer.
2010 State and School Employees Health Insurance Management Board TPA RFP
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FAILURE TO PROVIDE ALL OF THE REQUESTED INFORMATION HEREIN MAY
RESULT IN DISQUALIFICATION OF YOUR PROPOSAL.
1.3 Important Dates:
NOTE: The Board reserves the right to adjust this schedule, as it deems necessary.
December 20, 2010
January 7, 2011
January 14, 2011
February 14, 2011
Week of April 4, 2011
Week of April 18, 2011
April 27, 2011
January 1, 2012
RFP Released
“Intent to Propose” and “Questions” Due at the Office of Insurance
“Responses to Questions” Released
Proposals Due by 2:00 p.m. CST at the Office of Insurance
Presentations by Finalists (if deemed necessary by the Board)
Site Visits (if deemed necessary by the Board)
Vendor Selected
Contract Effective Date
Proposals must be received at the DFA-Office of Insurance in Jackson, Mississippi by 2:00
p.m. CST, February 14, 2011. Proposals received after the deadline will not be considered.
If deemed necessary by the Board, some proposers may be asked to make presentations in
Jackson, Mississippi. You will be given sufficient notification if you are requested to make
such a presentation. The Board will not incur any expense for such presentations. Should
site visits be deemed necessary by the Board, the Board will not incur any expense except
for those expenses related to travel by the Board’s staff.
Proposals must be delivered in a sealed package and clearly labeled with the words,
“Proposal - Do Not Open” prominently displayed on the outside of the package.
Proposers must submit one (1) original and eight (8) copies (with at least one copy to be
unbound) of their proposal, along with two (2) electronic copies in Microsoft Word®
format on compact disks, to the following address:
Edie Mills
Director, Benefits and Participant Services
Department of Finance and Administration Office of Insurance
901 Woolfolk Building, Suite B
501 North West Street
Jackson, Mississippi 39201
E-mail Address: emills@dfa.state.ms.us
Facsimile Number: 601-359-6568
1.4
Intent to Propose and Questions
All potential proposers are requested to indicate their intention to propose by January 7,
2011. Notice may be submitted via e-mail to Edie Mills at emills@dfa.state.ms.us or by
facsimile at (601) 359-6568. Your intent to propose should indicate your organization’s
2010 State and School Employees Health Insurance Management Board TPA RFP
Page 8
primary contact, direct telephone number of contact, e-mail address, and facsimile number.
The submission of a Notice of Intent to Propose does not obligate the vendor to submit a
proposal. Likewise, vendors are encouraged, but not required, to submit a notice of intent to
Propose. Questions must be submitted in writing, and must be received by January 7, 2011.
Responses to vendor questions received by January 7, 2011, will be made available on
DFA’s website at www.dfa.state.ms.us under “Bid and RFP Notices” by January 14, 2011.
It is the proposer’s sole responsibility to monitor the web site for responses to questions, as
well as any amendments to the RFP.
1.5 Statement of Compliance Requirement
Section 7 contains a Draft Contract and a Statement of Compliance. Please review these
sections carefully and include a Statement of Compliance signed by an officer, principal or
owner of the firm with your completed proposal. Failure to submit a signed statement of
compliance will result in your proposal being eliminated from further consideration.
1.6 Statutory Requirement
In accordance with Section 25-15-9(1)(a) of the Mississippi Code, each entity that submits a
proposal in response to this RFP must provide a disclosure statement detailing any services
or assistance it provided during the previous fiscal year to the Board and/or DFA in the
development of the State and School Employees’ Life and Health Insurance Plan. The
statement must include a detailed description of the proposer’s participation in the
development of the Plan, as well as any resulting compensation received from the Board
and/or DFA during the previous fiscal year. If you did not provide such assistance to the
Board and/or DFA, you must indicate in your disclosure statement that this provision does
not apply to you. A list of persons, agents, and corporations who have contracted with or
assisted the Board in preparing and developing the State of Mississippi State and School
Employees’ Life and Health Insurance Plan and a copy of the statutory requirement are
contained in Section 6. You must provide a statement whether or not the provision
applies to you. Failure to provide this disclosure statement will result in your proposal
being eliminated from further consideration.
1.7 Corrections and Clarifications
The Board reserves the right to request clarifications or corrections to proposals. Any
proposal received which does not meet the “Instructions to Proposers”, the “Minimum
Vendor Requirements”, or comply with other proposal requirements of this RFP, including
clarification or correction requests, may be considered to be “non-responsive” and may be
rejected.
1.8 Right of Negotiation
Discussions and negotiations regarding price and other matters may be conducted with
proposer(s) who submit proposals determined to be reasonably susceptible of being selected
for award, but proposals may be accepted without such discussions. The Board reserves the
right to further clarify and/or negotiate with the “proposer evaluated best” following
completion of the evaluation of proposals but prior to contract execution, if deemed
necessary by the Board. The Board also reserves the right to move to the next best proposer
if negotiations do not lead to a final contract with the best proposer. The Board reserves the
right to further clarify and/or negotiate with the proposer(s) on any matter submitted.
2010 State and School Employees Health Insurance Management Board TPA RFP
Page 9
1.9 Acknowledgment of RFP Amendments
Should amendments to the RFP be issued, it will be posted on DFA’s website at
www.dfa.state.ms.us under “Bid and RFP Notices”. Proposers must acknowledge receipt of
any amendment to the RFP by signing and returning the amendment form with their
proposal, identifying the amendment number and date in the space provided for this purpose
on the amendment form, or by letter. Amendment acknowledgment(s) must be delivered to
DFA-Office of Insurance in Jackson, Mississippi by February 14, 2011. It is the proposer’s
sole responsibility to monitor the website for amendments to the RFP.
1.10 Representation Regarding Contingent Fees
By submission of a proposal, the proposer represents that it has not retained any person or
agency to solicit or secure a contract for the services described herein upon an agreement or
understanding for a commission or a percentage, brokerage, or contingent fee. The Board
will not pay any brokerage fees for securing or executing any of the services outlined in this
RFP. Therefore, all proposed fees must be net of commissions and percentage,
contingent, brokerage, service, or finder’s fees.
1.11 Certification of Independent Price Determination
By submission of a proposal, the proposer certifies that the fees submitted in response to the
RFP have been arrived at independently and without – for the purpose of restricting
competition – any consultation, communication, or agreement with any other proposer or
competitor relating to those fees, the intention to submit a proposal, or the methods or
factors used to calculate the fees proposed.
1.12 Representation Regarding Gratuities
By submission of a proposal, the proposer represents that it has not violated, is not violating,
and promises that it will not violate any prohibition against gratuities as set forth in Section
7-204 (Gratuities) of the Mississippi Personal Services Contract Procurement Regulations.
A copy of the regulations may be obtained by contacting the Mississippi State Personnel
Board located in the Robert G. Clark Jr. Building at 301 North Lamar Street, Suite 100,
Jackson, Mississippi or by accessing the website at www.spb.state.ms.us.
1.13 Duration of Proposal
Within the proposal, you must state that your proposal/offer is valid for a period of at least
180 days subsequent to the date of submission. The proposal shall become part of the
Contract in the event that the contract is awarded to your organization.
1.14 Withdrawal of a Proposal
A proposer may withdraw a submitted proposal by submitting a written notification of its
withdrawal to the Board, signed by the proposer, and faxed, e-mailed, or mailed to Edie
Mills at the Office of Insurance. The Board shall not accept any amendments, revisions, or
alterations to proposals after the due date unless requested by the Board.
2010 State and School Employees Health Insurance Management Board TPA RFP
Page 10
1.15 Cost of Proposal Preparation
All costs incurred by the proposer in preparing and delivering its proposal, making
presentations, and any subsequent time and travel to meet with the Board regarding its
proposal shall be borne at the proposer’s expense.
1.16 Proposal Evaluation
All proposals received by the stated deadline will receive a comprehensive, fair and
impartial evaluation of proposals received in response to this Request for Proposal. The
evaluation of any proposal(s) may be suspended and/or terminated at the Board’s discretion,
at any point during the evaluation process in which the Board determines that said
proposal(s) and/or proposer(s) fails to meet any of the mandatory requirements as stated in
this RFP, the proposal(s) is determined to contain fatal deficiencies to the extent that the
likelihood of selection for contract negotiations is minimal, or the Board receives reliable
information that would make contracting with the proposer impractical or otherwise not in
the best interest of the Board and/or the State of Mississippi.
An evaluation committee will evaluate the proposals in the following three-phase process:
Compliance Phase - In this phase, all proposals received will be reviewed to determine if
the following mandatory requirements of this RFP have been satisfied:
a.
b.
c.
d.
e.
f.
g.
h.
Proposal submission deadline met
Minimum vendor requirements met
Required format followed
Original and requested number of copies of proposal provided
Signed Statement of Compliance provided and high degree of acceptance of
Contract terms provided
Narrative questionnaire answered
Duration of proposal requirement met
Required proposal attachments provided
Failure to comply with the mandatory requirements may result in rejection of a proposal.
This is a pass/fail evaluation. Those proposals passing the Compliance Phase will be
evaluated further. The Board reserves the right to waive minor informalities in a proposal in
this phase of the evaluation.
Analysis Phase - In this phase of the evaluation process, the evaluation committee will
judge responses received relative to the cost and technical merits of each proposal. Areas
are listed in order of their relative importance:
Claims Processing and Data Management - the demonstrated capability to process claims,
process eligibility information, perform billing functions, and maintain data files in an
efficient manner and in accordance with Plan requirements. (Critical)
2010 State and School Employees Health Insurance Management Board TPA RFP
Page 11
Experience with Large Employer Plans - the experience working with and processing claims
for employer groups of at least 100,000 covered lives including demonstrated experience
performing the full range of TPA functions listed in this RFP. (Critical)
Pricing - the quality, competitiveness, and economic value of the proposed administrative
fees, and the willingness to provide rate guarantees for five years. (Critical)
System Interface Capability - the demonstrated ability to coordinate the information flow
between the medical management vendor, pharmacy benefit manager, provider networks,
wellness and health promotion vendor and DFA; the demonstrated competence in providing
meaningful management reporting on a consistent basis that assists the Board in managing
and improving the Plan. (Very Important)
Customer Service - the demonstrated competence, capacity and willingness to develop a
comprehensive customer service plan to provide access to information and problem solving
assistance to the Board, Plan participants and providers. (Very Important)
Finalist Phase – At the conclusion of the Compliance Phase, one or more finalists will be
determined by the Board based on the interim scores. In this phase of the evaluation process,
the Board will endeavor to contact and verify references provided by finalist(s) in their
proposal(s), as well as any other references, at the Board’s discretion, that are, or may
become, known to the Board. During the reference verification, the evaluation committee
will seek to verify demonstration of an acceptable level of performance, customer
satisfaction, and a track record of successfully managing health benefit administration for
employer groups of a similar size and complexity as the Board's Plan. This phase may also
include, at the discretion of the Board, any or all of the following:
Finalist presentations, if deemed necessary by the Board, will consist of technical “question
and answer” interviews to be conducted in Jackson, Mississippi, to allow finalist(s) the
opportunity to showcase their service abilities. Board members, consultants and staff may
use this opportunity to clarify or verify information provided by the vendor in the submitted
proposal.
On-site reviews, if deemed necessary by the Board, will be conducted to clarify or verify the
proposer’s proposal and to develop a comprehensive assessment of the vendor.
The Board specifically reserves the right to reject any or all proposals received in response
to the RFP, cancel the RFP in its entirety, or issue another RFP.
Subsequent to award and contract execution, the Board agrees to conduct upon request a
debriefing with any proposer not selected, for the purpose of providing general as well as
specific information regarding the quality of his/her proposal, subject to any applicable
confidentiality and/or non-disclosure requirements and in accordance with the applicable
regulations of the Mississippi Personal Services Contract Review Board.
2010 State and School Employees Health Insurance Management Board TPA RFP
Page 12
1.17 Mississippi Public Records Act/Confidentiality of Proposals
Any proposal, including accompanying attachments, will be available for review by State of
Mississippi personnel, the Board, members and staff of the Legislature and oversight
boards, the Plan’s Advisory Council, and the Board’s consultants. The proposal is further
subject to the “Mississippi Public Records Act of 1983,” codified as Section 25-61-1 et seq.,
Mississippi Code Annotated and exceptions found in Section 79-23-1 of the Mississippi
Code Annotated. The Board understands that you may consider some of the information
required to be provided in the proposal to be proprietary.
The Board requests that each page of the proposal that you consider confidential be on
a different color paper than non-confidential pages and be marked in the upper right
hand corner with the word “CONFIDENTIAL.”
The statute listed above provides that you may request that prior to the release of any
information that you will be notified by the Board of the request for the information and
given sufficient time to seek protection from the appropriate court. If you do not obtain
protection from the appropriate court, all information supplied whether marked confidential
or not, may be released. The Board will accept no additional restrictions on the release of
information contained in your proposal.
Any contract resulting from this RFP will be subject to the provisions of the Mississippi
Accountability and Transparency Act of 2008 (MATA), codified as Section 31-7-13 of the
Mississippi Code Annotated (1972, as amended). Unless exempted from disclosure due to a
court-issued protective order, the contract is required to be posted to the Department of
Finance and Administration’s independent agency contract website for public access. Prior
to posting the contract on the website, any information identified by the TPA as trade
secrets, or other proprietary information including confidential vendor information, or any
other information which is required confidential by state or federal law or outside the
applicable freedom of information statutes will be redacted.
1.18 Right to Consider Historical Information
The Board reserves the right to consider historical information regarding the proposer,
whether gained from the proposer’s proposal, question and answer conferences, references,
or any other source during the evaluation process. This may include, but is not limited to,
information from the Mississippi Insurance Department, as well as any other State or federal
regulatory entity.
1.19 Right to Reject, Cancel and/or Issue Another RFP
The Board specifically reserves the right to reject any or all proposals received in response
to the RFP, cancel the RFP in its entirety, or issue another RFP.
2010 State and School Employees Health Insurance Management Board TPA RFP
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2
Minimum Vendor Requirements
The following proposal requirements are mandatory. Failure to meet any of these proposal
criteria will result in the disqualification of the proposal submitted by your organization.
Please respond by restating each vendor qualification and describing how your
organization meets these minimum criteria.
a.
Currently provides TPA services to employer clients with at least 500,000 covered
lives in aggregate (covered lives include active employees, COBRA, retirees and
dependents for all classes), with at least one client with at least 100,000 covered
lives. Please indicate how you meet this criterion, including the employer name,
address, contact, title, phone number, fax number, size of group, and number of
years the contract has been in place with your organization.
b.
Possess at least ten years’ experience as of January 1, 2011, as an organization
providing Third Party Medical Claims Administration Services. Please indicate
how you meet this criterion.
c.
Currently employ or contract with a full-time Medical Director. Please indicate
how you meet this criterion.
d.
Agree to operate a Service Center in Mississippi to include, at a minimum, provider
and exclusive participant customer service, account service to the Board (including
the exclusive customer service representative and the dedicated account manager),
and enrollment and billing functions. Please confirm.
e.
Agree that all services performed on behalf of the Board will be provided within the
Continental United States. Please confirm.
f.
Agree to interface with the Statewide Payroll and Human Resource System
(SPAHRS) as described in Section 3 – Scope of Services. Please confirm.
g.
Agree to provide a $3,000,000 implementation bond, naming the Board as
exclusive beneficiary, to guarantee timely and complete establishment of the
contract and related services. Any failure of the TPA to perform timely and
complete establishment of such services shall result in damages recoverable by the
Board against the TPA’s implementation bond. Upon the Board’s agreement that
the TPA has complied with its implementation responsibilities, the implementation
bond shall be released. Please confirm.
h.
Agree to provide and maintain a $2,000,000 fidelity bond with the Board named as
exclusive beneficiary for the duration of the relationship. Please confirm.
i.
Agree to place at least 20% of all administrative fees at-risk for the TPA’s
compliance with mutually agreed upon performance standards. Please confirm.
2010 State and School Employees Health Insurance Management Board TPA RFP
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3
Scope of Services
This section contains information on services and procedures that the TPA must provide or adhere
to in servicing the Board’s account. The descriptions below are not all-inclusive, but are provided
to alert you to services or procedures that may require additional planning or programming on your
part. Please review this section carefully. If you object to any of the services or procedures listed
in this section, please note and explain your objection in detail on the Scope of Services Statement
of Compliance. Proposer must submit a signed Scope of Services Statement of Compliance.
3.1 Dedicated Account Service
All services directly related to this contract must be provided from an office located within
the Continental United States. A Customer Service Center must be located in Mississippi to
serve the Board, providers and Plan participants. The TPA must assign a dedicated (but not
necessarily exclusive) account manager, located in the Mississippi Service Center, to
participate in activities relative to all aspects of the contract between the Board and the TPA.
When the Board provides the TPA with written notification of a significant issue, the TPA
will respond in writing to the Board with the resolution of the issue or an explanation of
when the issue can be resolved, with a defined timetable, within an average (as measured on
an annual basis) of two (2) business days.
3.2 Exclusive Customer Service Representative
The TPA must designate an exclusive customer service representative, located in the
Mississippi Service Center, to the Board’s account to receive and respond to inquiries and
complaints. The dedicated customer service representative must maintain records of all
inquiries/complaints and the disposition, including but not limited to, date of
inquiry/complaint received; party making inquiry of complaint; description of
inquiry/complaint; disposition and date of disposition.
3.3 Staffing
The TPA will hire and maintain sufficient staff to meet the needs of the Board and the Plan
participants. The TPA will report quarterly on the volume of calls received and the type of
calls received.
3.4 Communication Materials/Forms
The TPA is responsible for designing, printing and distributing customized brochures,
posters, and forms, with the Board’s approval, as necessary and required to install and
administer the services to Plan participants, employer units, and the Board.
3.5 Identification (ID) Cards
The Board requires custom identification (ID) cards to identify Plan participants. The TPA
is responsible for producing Plan participant ID cards, and mailing ID cards to the
participant’s home address. The TPA will be responsible for mailing, within five days, ID
cards under the following circumstances:
a.
b.
Initial enrollment of the Plan
New hires
2010 State and School Employees Health Insurance Management Board TPA RFP
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c.
d.
e.
Enrollees who change coverage category (e.g. single to family)
Replacement of lost cards
Upon request of a participant
A copy of the current ID card layout is located in Appendix D.
3.6 Vendor System Interface
The TPA is responsible for the electronic exchange of claims, provider, and eligibility file
and related information to and from the Board vendors. A vendor interface diagram is
located in Appendix E. Current electronic transfer requirements are as follows:
Pharmacy Benefit Manager (Currently Catalyst Rx) - each month, detailed claims data by
participant ID number will be transferred by PBM to the TPA for purposes of tracking
benefit maximum accumulations. Eligibility data (changes, additions, terminations) will be
transferred by the TPA to the PBM weekly.
Medical Management Vendor (Currently ActiveHealth Management) - each day,
inpatient/outpatient pre-certification review and case management data will be transferred to
the TPA. Each week, eligibility data will be transferred by the TPA to the Medical
Management vendor. Detailed claims data is transferred to the Medical Management
Vendor by the TPA on a weekly basis for purposes of administering the Plan’s medical
management program. A network provider file is transferred each week from the TPA to
the Medical Management vendor.
Data Management Vendor (Currently Thomson Reuters) - comprehensive claims and
eligibility data will be transferred to the Data Management Vendor each month.
Wellness and Health Promotion Services Vendor (Currently WebMD) - Each week, the
TPA will transfer eligibility data to the Wellness and Health Promotion Services Vendor.
Health Risk Assessment fulfillment by participant is transferred from the Wellness and
Health Promotion Vendor to the TPA daily. Detailed claims data is transferred to the
Wellness and Health Promotion Vendor by the TPA on an annual basis.
Provider Network Administrator (Currently Advanced Health Systems) – each week,
participating provider information is transferred from the Provider Network Administrator
to the TPA. Provider rate information is transferred to the TPA annually. In addition,
Advanced Health Systems contracts with a national network provider. The TPA is
responsible for the electronic transfer of non-network, out-of-state, institutional claims to
the national network for re-pricing. Once re-priced, these claims are returned to the TPA for
processing. An interface diagram demonstrating this process is located in Appendix F.
The Statewide Payroll and Human Resource System - The Statewide Payroll and Human
Resource System (SPAHRS) is an integrated, mainframe-based, centrally controlled
enterprise payroll and human resource system utilized by State agencies. The Mississippi
Management and Reporting System, a division of the Department of Finance and
Administration is responsible for maintaining SPAHRS. Life and health insurance data
(additions, terminations, changes) are transferred nightly from SPAHRS to the TPA using
2010 State and School Employees Health Insurance Management Board TPA RFP
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the HIPAA 834 file layout. The TPA uses this file to add/update subscriber and dependent
records and in turn transfers a confirmation file back to SPAHRS indicating the status
(accepted, rejected, pending) of data submitted. Records that could not be accepted or are
pending must be returned on a separate file, along with the reason the transaction could not
be accepted or is pending. As the status of pending records is resolved, a third file must be
returned with the record and resolution (accepted or rejected). Records on files returned to
the Mississippi Management and Reporting System (MMRS), a DFA agency, are not
required to utilize the HIPAA 834 file layout but must contain data to properly identify the
corresponding SPAHRS record.
3.7 On-Line Access for Board Staff
The TPA must provide, at its own cost, the Board staff on-line access to
claim/membership/eligibility information. On-line access must allow for inquiry only
including historical eligibility and claims information. In addition to inquiry only access,
the TPA is required to provide an electronic enrollment process to the Board for the purpose
of enrolling eligible retiree coverage. This electronic enrollment process is consistent with
the electronic enrollment process for employer units not using the SPAHRS found in
Section 3.23, Enrollment and Eligibility, of this RFP.
3.8 Claims Administration
The TPA is responsible for maintaining a system for processing, adjudicating, and recording
of claims for benefits in accordance with the Plan Document, located in Appendix B, any
applicable requirements established by the Board and any modifications or changes as
communicated by the Board or as required by federal or state law. The TPA must maintain
the resources, flexibility, and innovation to update and change the claims processing system
as required by the Board. The TPA is responsible for reviewing submitted claims
information for completeness and requesting any additional information necessary for
proper adjudication of the claim in a timely manner. The claims payment system must be
capable of accepting both electronic and paper submitted claims. In 2009, the TPA received
approximately 2.2 million claims. Of the claims received, 95% represent electronically filed
claims, with the remaining 5% representing paper claims. The Claim Administrator does
not provide the provider network or medical management services. These services are
provided under separate contracts.
The Claim Administrator must have the capabilities to detect and report potential fraud and
abuse cases; cross-reference family deductible accumulations when married employees are
both participants of the Plan; compare total charges against total payments; identify
duplicate charges; compare number of inpatient hospital days on each claim against
admission and discharge dates; verify services are provided within the employee's eligibility
date and maintain breaks in active service; recognize historical benefit maximums; identify
excess "usual, customary and reasonable" charges for all procedures; identify potential
pre-existing conditions; verify provider license to the type of procedure billed; reconcile the
diagnosis code to the procedure and sex code for consistency; compute benefit year
deductibles; integrate in-network deductible accumulations with out-of-network deductibles
requirements; identify and maintain information on potential coordination of benefits,
subrogation, and other party liability situations; verify out-of-pocket amounts; review age
limits for eligibility or coverage limits; determine coinsurance levels; identify unbundling of
2010 State and School Employees Health Insurance Management Board TPA RFP
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services, up coding of services, obsolete or invalid codes; identify ineligible services; apply
multiple surgery guidelines; receive and process claims from Medicare for secondary
coverage payments; track and process network provider fee schedules to include percentage
of charge (POC), per diem rates, Ambulatory Payment Group (APG), Ambulatory Payment
Classification (APC), and DRG reimbursements.
Additional TPA services include, but are not limited to, the following: Preparing and
distributing 1099 forms for providers, filing of reports on the behalf of the Board as required
by federal and State law, production and distribution of claim forms, communicating in a
timely manner to all Plan Participants and employer units procedures for filing claims,
interpreting EOBs, filing appeals, making changes in eligibility, and related actions.
The TPA must maintain the following information for all claims: employee name, employee
identification number, patient name or other specific identifier, claim number, provider
number, provider name, service date, type of service, amount of charges, co-payment
amount, amount allowed to the claimant, and reason codes that specify the reason for claim
payment/nonpayment. The information contained in the explanation of benefits must be
available for inspection upon request by the Board. The Board will have access to all claims
and related information utilized in the issuance of payments to Plan participants and all
providers.
3.9 Run-Out Claims Administration
Upon termination of the contract, the TPA is responsible for adjudicating and processing all
claims with service dates prior to the termination date of the contract that are received by the
TPA within 180 days after the termination date.
3.10 Quality Control
The TPA will maintain formal policies and procedures regarding quality control. Quality
control processes will be applied to regularly evaluate and ensure that the performance and
accuracy of all areas of administration including, but not limited to, claims processing,
customer service, and enrollment/eligibility, meet the performance measures established by
the Board.
3.11 Provider Coding Accuracy
The TPA must utilize a system designed to evaluate coding accuracy and appropriateness
relative to International Classification of Disease (ICD) and Physicians Current Procedural
Terminology (CPT) coding and other coding references.
3.12 Hospital DRG Validations and Bill Audits
The TPA is responsible for initiating hospital DRG validations, charge/bill audits, and
professional bill audits within one year from the day the claim was processed. The TPA
will provide to the Board reports of its findings in a format approved by the Board.
3.13 Credit Balance Recovery
The TPA is responsible for performing credit balance and overpayment recovery services as
agreed upon by the Board within one year from the date the overpayment was detected. The
TPA will provide to the Board reports of its findings in a format approved by the Board.
2010 State and School Employees Health Insurance Management Board TPA RFP
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3.14 Price Negotiation
The TPA must ensure that any claim for which another vendor of the Board has negotiated
specific pricing contingent on a defined timeframe of adjudication is adjudicated within the
defined timeframe.
3.15 Eligibility Verification
The TPA is responsible for verifying the eligibility for participants for benefits under the
Plan based on the information provided by the employer units, participants, and DFA.
3.16 National Provider Indicator
The TPA’s claims processing system must be capable of maintaining standard unique
identifiers for health care providers in accordance with the Administrative Simplification
provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
3.17 National Drug Codes
The TPA’s claims processing system must be capable of capturing and storing National
Drug Codes.
3.18 Pre-existing Condition Determinations
The TPA is responsible for making pre-existing condition determinations, where applicable,
by reviewing enrollment information and any needed medical records. The TPA must order
medical records when necessary, review medical records for pre-existing conditions and
advise the participant of the pre-existing determination.
3.19 Pre-Determination of Benefits
The TPA is responsible for reviewing requests for pre-determination of benefits for
outpatient services based on the medical necessity of a particular case. The Plan participant
and provider must be notified of the determination of denial or approval within fifteen (15)
calendar days of receipt of the request.
3.20 Participant and Provider Customer Service
The TPA is responsible for responding to inquiries from Plan participants, providers, and
the Board regarding the services provided by the TPA through a toll free telephone line.
The normal service hours, in Central Time, are 7:00 a.m. to 6:00 p.m. Monday through
Friday. In addition, a voice message system shall be available 24-hours, 7 days-a-week,
other than scheduled maintenance times, to Plan participants and providers.
The TPA is responsible for maintaining a separate participant customer service area with a
separate toll-free number for participants. The TPA must maintain a well-trained exclusive
customer service department for Plan participants capable of addressing all benefit and
procedure questions. In 2009, the current TPA received 215,288 calls from Plan
participants.
2010 State and School Employees Health Insurance Management Board TPA RFP
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The TPA is responsible for maintaining a separate provider customer service area with a
separate toll-free number for verification of participant eligibility, benefit questions, and
claims status, and if requested, an estimate of allowable charges. In 2009, the current TPA
received 57,911 calls from health care providers. In addition, the TPA is responsible for
maintaining an automated phone system for providers for verification of participant
eligibility, benefit summaries, deductible and co-insurance maximum accumulation amounts
and claims status. This automated phone system must be available twenty four (24) hours,
seven (7) days a week. In 2009, the current TPA received 140,083 calls through the
automated phone system.
The TPA is responsible for maintaining an automatic call distribution system capable of
tracking and reporting phone activity for both participant and provider customer service tollfree numbers.
The TPA is required to participate in activities with the Board in responding to Plan
participant or provider inquiries or complaints relating to TPA services.
The TPA must cooperate with the Board and with all other contractors of the Board with
respect to ongoing coordination and delivery of health care services and in any transition of
responsibilities.
The TPA is responsible for responding to inquiries from employer units concerning
administrative procedures and benefits.
3.21 Provider Website
The TPA must provide a secure provider service website where routine provider service
inquiries can be handled. Information available through this website must include, but is not
limited to, eligibility and benefits information, deductible accumulation, claim status, and
on-line viewing of provider vouchers.
3.22 Electronic Payment to Providers
The TPA must provide a system capable of electronic deposit of funds for health care
providers.
3.23 Enrollment and Eligibility
The TPA system must process and maintain enrollment and eligibility information for the
health insurance component as well as the life insurance component of the Plan for the more
than 195,000 Plan participants, including employees, dependents, retirees, and COBRA
participants. The TPA will receive enrollment and eligibility information from the following
groups:
All Employer Units (approximately 330 State agencies, universities, community/junior
colleges, libraries, and school districts)
DFA (initial retiree applications only)
Mississippi Public Employees' Retirement System (PERS)
Retirees
COBRA participants
2010 State and School Employees Health Insurance Management Board TPA RFP
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The TPA must be able to receive and process enrollment data in both hard copy and
electronic format. While the majority of employer units currently transmit and receive
enrollment and eligibility information to the TPA in paper format, approximately 100
employer units currently use the Statewide Payroll and Human Resource System (SPAHRS)
system for enrollment/eligibility additions, terminations, and changes. Payroll/personnel
staffs enroll newly-hired employees and make updates to existing employees’ coverage by
entering the appropriate electronic transactions from the health and life insurance forms
completed by the employees.
The transactions are sent each night via electronic transfer to the TPA through the SPAHRS,
and once accepted, the enrollment records with the TPA are updated. Each night, SPAHRS
looks for health and life insurance transactions that have been modified since the last date a
file was created for the TPA. When a transaction is found, the last one entered on the log
file is compared to the previous date’s data. If there is a change in the TPA’s data, that
record is selected to be sent on that night’s file. The data is sent to the TPA using selected
records from the HIPAA 834 file layout. The TPA takes the data and converts it to values
needed for their system and edits the data to see if it can accept it. A confirmation file is
returned that identifies the transaction and whether it is accepted, rejected, or placed on
hold. MMRS uses the confirmation file to update the status in SPAHRS. An error/reason
file is also returned that indentifies the transaction and why it could not be accepted or why
it was placed in a pending status. Pending record status usually occurs when additional
information must be received by the TPA before a determination of accept/reject can be
made. A nightly file is also received for pending records that have been resolved and what
the resolution is (accepted/rejected) and the status in SPAHRS is updated accordingly.
Refer to Appendix G, hold file layout, used for transactions that cannot be accepted or
rejected until further information from the employer unit has been received. The TPA is
required to allow for transactions to be placed in a hold status. The TPA is also required to
provide on-line access to the hold file to the Board to approve/reject transactions and return
such decisions to the TPA via electronic means.
Any information system proposed, developed, or modified that disseminates, in any form or
manner, information or material that contains the Social Security Number of an individual,
must include mechanisms in place to prevent the inadvertent disclosure of the individual’s
Social Security Number to members of the general public or to persons other than those
persons who, in the performance of their duties and responsibilities, have a lawful and
legitimate need to know the individual’s Social Security Number as required by Section 251-111 of the Mississippi Code Annotated.
The proposer must meet the Board’s requirements for Virtual Private Network (VPN)
connection to State VPN concentrator for File Transfer Protocol (FTP), as well as comply
with other aspects of the security policy of the Information Technology Services (ITS), an
agency of the State of Mississippi. For more information on these requirements and/or to
obtain a copy of the Mississippi Enterprise Security Policy, click on the following:
http://www.its.ms.gov/security/docs/confidentiality_agreement_for_its_esp_for_web.pdf.
2010 State and School Employees Health Insurance Management Board TPA RFP
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Mississippi’s Accountability System for Government Information and Collaboration
(MAGIC) is the State’s Enterprise Resource Planning (ERP) project scheduled to replace
the State’s accounting system SAAS in 2013. The next phased implementation will replace
SPAHRS in 2014; therefore, the SPAHRS process must be migrated to MAGIC once it is
implemented.
Acceptance Testing: The purpose and net result of the acceptance test is to determine that
the system proposed and installed meets the technical and functional requirements outlined
in this RFP. A system considered “acceptance test ready” is defined as a system that has
completed a full system test with no known outstanding material defects.
The awarded proposer will be required to provide a proposed “Acceptance Test Plan” (ATP)
prior to acceptance testing of the system by the Board. The awarded proposer must show
events, sequences and schedules, to include stress testing and regression testing, required for
acceptance of the system. The Board will provide written approval that the proposed ATP is
complete and acceptable prior to the beginning of the acceptance testing. The ATP will be
considered a task completion deliverable. The awarded proposer must allow for a final
acceptance-testing period of up to 30 calendar days in accordance with the work plan
delivery schedule.
A high-level project plan including the full scope of implementation services for electronic
enrollment described will be required. The project plan must demonstrate a suggested
overall approach, sequence, required Board staff, and dependencies for accomplishing the
Board’s objectives as outlined in this RFP. The Board and awarded proposer will work
together throughout the term of the contract to update and maintain the project plan.
Refer to the Office of Insurance Electronic Enrollment Training Manual located in
Appendix H. This manual discusses the Electronic Enrollment process and provides
employer units information needed to correctly enter transactions and instructions on how to
correct related errors. Also refer to the Office of Insurance Electronic Enrollment
Resolution Guide located in Appendix H. This guide provides resolutions for employer
units to correct electronic enrollment errors.
The TPA is required to provide an electronic enrollment process option for those employer
units not using SPAHRS. The TPA will be responsible for the initial load of eligibility data
base, including coverage history and ongoing eligibility additions/deletions/changes. The
electronic enrollment process for those employer units not using SPAHRS is currently
underway. Depending on the size of the employer unit (those having a small number of
employees), some employer units may elect to remain paper-based. Therefore, the TPA is
responsible for accepting and processing paper-based enrollment.
The TPA is required to participate in training sessions relative to enrollment/eligibility
policies and procedures for SPAHRS and conduct training sessions for non-SPAHRS and
paper-based employer units. The number of training sessions is dependent on many factors
including payroll/personnel staff turnover, changes to enrollment/eligibility requirements,
updates/changes in the SPAHRS system, etc. The Plan's current enrollment information is
included in Appendix A.
2010 State and School Employees Health Insurance Management Board TPA RFP
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3.24 Premium Billing and Account Reconciliation
The TPA is required to provide and maintain a premium billing and accounts receivable
system which is capable of producing monthly statements, tracking account balances and
documenting payment histories for medical and life premiums. The billing and receivable
system will manage medical and life premium reporting and collection for the Plan. The
billing statements are based on the employer/employee premium contribution requirements
as authorized by the Board. The premium billing system must be capable of pro-rating
monthly premium contributions based on the participant’s eligibility date. Each month, the
TPA will produce approximately 330 paper billing statements for employer units, nearly
850 paper billing statements for COBRA participants, and approximately 1,000 paper
billing statements for direct-bill retirees.
Employer unit monthly billings currently include three sections:
a.
b.
c.
Employer unit billing statement that includes remittance information, and a
summary of the unit’s current amount due and any past due amount,
Premium billing section that includes a current list of employees participating in the
unit, the last 4 digits of the participant’s Social Security numbers, payroll locations
(if used by your unit), life face value and premium amount, health premium and the
total premium for each employee, and
Past due detail analysis section that lists information regarding any past due
amounts.
In addition to paper billings, the TPA is required to produce an electronic billing file
containing all employer unit statements and provide same to the Board. Currently, the
electronic billing file is distributed to employer units by the Board. The current electronic
billing file layout is located in Appendix I. Alternatives to the current electronic billing file
distribution process, such as secure on-line access, will be considered.
The TPA must provide a bank draft payment option for COBRA participants and direct-bill
retirees. Currently, approximately 550 bank draft transactions are processed per month.
Employer units keep the TPA informed of any changes in the enrollment status of
employees and their covered dependents. Each employer unit is responsible for prompt and
accurate reconciliation of the monthly premium billing. The monthly premium billing is
reconciled with payroll deduction records and a Premium Billing Reconciliation Form
(recap) is completed by the employer unit. The recap is submitted to the TPA on or before
the tenth of each month to ensure that the requested and appropriate changes can be made to
enrollment records prior to the next billing cycle. The TPA is responsible for determining
the appropriateness and Plan compliance of adjustments made by employer units based on
eligibility listings and reconcile the accounts receivable each month based on premium
payments and additions, terminations, and changes submitted by employer units. The TPA
is required to maintain adequate personnel for purposes of maintaining eligibility and
premium billing/reconciliation functions. The Plan's current enrollment structure is
included in Appendix J.
2010 State and School Employees Health Insurance Management Board TPA RFP
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3.25 Public Employees’ Retirement System Billing Report
The TPA must produce an electronic monthly billing (deduction) report on retirees whose
premium contributions are deducted by the Public Employees retirement System (PERS).
The PERS billing report must be produced and sent to PERS by the 10th of each month for
the following month’s premiums. The report will include the retiree’s name, social security
number, and premium amount (medical and life). The TPA is responsible for updating
eligibility records based on the edit report and address changes provided by PERS. The
current PERS billing report file layout is located in Appendix K. Retirees who no longer
receive sufficient pension benefits to fund their premium requirements will be transferred by
the TPA to a direct-bill status.
3.26 Eligibility Files
The TPA will be required to maintain HIPAA compliant information on each Plan
Participant. In addition to such information, the Board requires that the following
information be captured and maintained in the TPA's eligibility system:
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
m.
n.
o.
Participant’s name, date of birth, home address, phone number and e-mail address
Participant’s unique identification number
Participant’s and dependent’s Social Security Number
Dependent child’s address (if different than parent)
Effective dates of coverage, changes and terminations for participants and
dependents
Subgroups - The Plan currently has eight (8) subgroups which include active
employees, COBRA participants, Medicare eligible service or disabled retirees over
65, Medicare eligible disabled retirees under 65, disabled retirees without Medicare,
service retirees without Medicare, active employees with life insurance only
coverage and retirees with life insurance only coverage. Enrollment structure
information is included in Appendix J.
Participant’s marital status
Participant’s Employer Unit identifier
Participant’s payroll location
Life insurance amount and beneficiary name
Qualifying event timeframe (i.e. 18 months, 36 months) for COBRA participants
Family Cross-Reference - The Plan requires that active employees be covered under
their own individual contract and prohibits active employees from being covered as
a dependent under another Plan contract. Also, a dependent child can be covered
under only one Plan contract. Family cross-reference is also required for the
accumulation of the family deductible
Disabled Dependents - The TPA is responsible for verifying, through medical
review, that the dependent qualifies for continued coverage as a disabled dependent.
Eligibility History - Historical information to be maintained includes, but is not
limited to, prior contract types (e.g. single, family), prior coverage dates for
dependents prior subgroups, etc.
On-line Membership/Eligibility - The TPA must provide Board staff read-only
access to membership/eligibility and claims information via an on-line system.
2010 State and School Employees Health Insurance Management Board TPA RFP
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3.27 Storage and Retrieval of Enrollment Forms
The TPA must have the capability of electronic scanning, storage, and retrieval for health
and life enrollment forms submitted for initial enrollment and enrollment/status changes.
3.28 Life Insurance Support Functions
The Board currently contracts for a fully insured group term life insurance policy with
Minnesota Life Insurance Company to provide a fully insured group term life insurance
policy for eligible employees and retirees of State agencies, universities, public libraries,
and certain community/junior colleges and public school districts. Life insurance coverage
is available to employees and retirees only; dependent life insurance coverage is not
available.
The TPA must maintain life insurance eligibility records and provide the
following services:
a.
b.
c.
d.
Maintenance and update of beneficiary designations
Updates in the participant's life insurance benefit amount
Premium billing and reconciliation
Electronic storage and retrieval of life insurance enrollment/change forms
The TPA is responsible for calculating monthly life insurance premiums due from the
participant and from the employer unit (active employees only), based on the total premium
due for the appropriate coverage amount, and including this information on the employer
unit billing statements, direct bill statements and PERS deduction report.
3.29 COBRA Administration
The TPA is responsible for providing full administration of the Consolidated Omnibus
Budget Reconciliation Act (COBRA), including, but not limited to:
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
Maintenance of all COBRA eligibility
Initial notification for participants who experience a qualifying event
Receipt and maintenance of rejection forms
60 Day Notice of End of Election Period
Premium Request after Election
45 Day Termination for Non Payment after Election
Complete Monthly Billing for all COBRA participants with return envelope
Provide Non-Sufficient Funds Notice
Provide required 180 day warning for end of continuation period
Notify insured of termination for non-payment of premium or any other reason
Notify insured of termination for end of continuation period
COBRA participant monthly premium billing, collection, and reconciliation
Refer to the Plan Document located in Appendix B for a detailed description of the Plan’s
COBRA provisions. Also refer to the Insurance Procedure Manual located in Appendix L
for a detailed description of COBRA responsibilities of employer units.
3.30 Coordination of Benefits (COB) Administration
The TPA will be responsible for providing full COB services. The necessary information
concerning primary coverage for participants and their dependents and other coverage
2010 State and School Employees Health Insurance Management Board TPA RFP
Page 25
extended via other carriers or benefits systems must be encoded into the TPA’s claims
processing system and tracked and managed via the system. To administer the coordination
of benefits, the TPA must exchange information with other plans involved in paying claims,
request that the participant/provider furnish any necessary COB information, reimburse any
plan that made payments that this Plan should have made, and recover any overpayment
from health care providers and other insurance companies as necessary. If this Plan should
have paid benefits that were paid by any other plan, the TPA will pay the plan that made the
other payments in the amount the Plan determines to be proper under COB provisions.
3.31 Subrogation Administration (Third Party Liability and Work-Related)
As a condition to receiving medical benefits under the Plan, participants agree to transfer to
the Plan their rights to recover damages in full for such benefits when the injury or illness
occurs through the act or omission of another person. Benefits for work-related injuries or
illnesses may be extended by the Plan where (1) liability is being controverted by the
employer in a proceeding before the particular worker’s compensation agency with
jurisdiction and Plan participant’s related claims are unpaid; or, (2) claims payments were
made prior to notification to the Plan of their work-related nature. The TPA is responsible
for full subrogation administration, including, but not limited to, efficiently identifying those
cases that quality for subrogation and the legal pursuit thereof.
3.32 Overpayment/Recovery Administration
The TPA will identify, collect and post overpayments from participants and providers in a
timely manner. Overpayments will be posted to the Plan participant’s individual claims
account.
3.33 Medicare Secondary Payer (MSP)
The TPA will be responsible for all functions related to Medicare Secondary Payer (MSP)
post-payment recoveries.
3.34 Satisfaction Survey
The TPA must conduct at least one (1) Plan participant satisfaction survey annually. The
format and process for conducting the survey must be presented to and approved by the
Board.
3.35 Appeal and Grievance Procedures
The TPA must administer appeal and grievance procedures in accordance with all
regulations required by Patient Protection and Affordable Care Act (PPACA). A participant
has the right to appeal any decision that denies payment of a claim or a request for coverage
of a health care service or treatment. If a participant believes that the TPA incorrectly
denied all or part of a claim, he has the right to obtain a full and fair review. A request for a
review must be made in writing to the TPA.
The participant has 180 days to request a review after receiving notice of denial from the
TPA. The participant may provide additional information that relates to the denied claim.
If the participant fails to request a review within this timeframe, the right to review is
forfeited.
2010 State and School Employees Health Insurance Management Board TPA RFP
Page 26
After the claim has been reviewed, and benefits are again denied, the decision will be sent to
the participant in writing. The letter will include the reason(s) why benefits are denied, with
reference to the Plan provisions on which the decision is based.
If, after following the appeal procedure described above, the participant still disagrees with
the determination, a final internal appeal may be submitted in writing to the Department of
Finance and Administration, Office of Insurance within 30 days of the second denial. The
request to the Office of Insurance must include a copy of TPA’s review decision and all
information pertinent to the claim. The decision of the State Insurance Administrator with
the Department of Finance and Administration, Office of Insurance is final and concludes
all internal levels of appeal.
Within four months after the date of receipt of a final internal denial of a claim, the
participant may file a request for an external review. An external review is available when
the final denial involves an issue of medical necessity, appropriateness, health care setting,
level of care, or effectiveness. The participant will be required to authorize the release of
any medical records that may be required to be reviewed for the purpose of reaching a
decision on the external review. The request must be made through the Office of Insurance
and must include all information pertinent to the denied claim. An external review decision
is binding on the participant except to the extent the participant has other remedies available
under applicable federal or State law. Failure to request a review within the above
referenced time frames and in accordance with the procedures will result in the participant’s
right to an appeal and rights to sue being forfeited.
3.36 Independent Review Organizations
The TPA is required to maintain contracts with a minimum or three (3) independent review
organizations (IRO) that are accredited by URAC or by a similar nationally-recognized
accrediting organization to conduct external reviews as required by PPACA.
3.37 Medical Director
The TPA must provide the services of a medical director to support the claims management
of the Plan. The medical director will be required to provide support in participant benefit
appeals and benefit determinations. Support functions may include, but are not limited to:
pre-determination of benefits, pre-existing condition determinations, medical necessity, and
experimental or investigative procedures.
3.38 Medical Review Department
The TPA must provide a well-staffed medical review department to administer those
functions listed under “Medical Director”.
3.39 Medical Policy
The TPA is responsible for maintaining medical policies on medical services/procedures.
Medical policy must be based on scientifically based evidence provided through research for
a particular medical technology. Medical policy must also be based on data from peerreviewed scientific literature, from criteria developed by specialty societies and from
guidelines adopted by other health care organizations.
2010 State and School Employees Health Insurance Management Board TPA RFP
Page 27
3.40 Training Personnel
The TPA is required to participate in training sessions relative to enrollment/eligibility
policies and procedures. The number of training sessions is dependent on many factors
including payroll/personnel staff turnover, changes to enrollment/eligibility requirements,
updates/changes in the SPAHRS system, etc. The TPA must provide field representative
personnel to conduct such employer/employee training sessions, including individual
meeting with employers as needed. The TPA is also required to provide field representative
personnel to conduct training for health care providers relative to claims filing procedures,
electronic submission of claims, and other health care provider related issues.
3.41 Explanation of Benefits
The TPA's explanation of benefits (EOB) form and provider payment voucher must
facilitate the separation of non-covered amounts, provider discounts, and the patient's
financial responsibility amount. The TPA must issue EOBs for every claim filed, including
zero-balance EOBs. The TPA must also provide the capability for participants and providers
to access, download, and print EOBs on-line. At a minimum, the explanation of benefits
must include:
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
m.
n.
o.
p.
Name and Address of TPA
Toll-Free Number for TPA
Participant’s Name/Address
Participant’s Identification Number
Patient's Name
Provider’s Name
Claim Date of Service
Type of Service
Total Charges
Discount Amount
Allowed Amount
Excluded Charges
Amount Applied to Deductible
Co-Payment/Coinsurance Amount
Total Patient Responsibility
Total Payment Made and To Whom
3.42 HIPAA Exemption
The Board has elected to exempt the Plan, as a non-federal governmental plan, from certain
requirements of the Health Insurance Portability and Accountability Act. The Board,
however, has elected to generally comply with the intent of the requirements voluntarily.
3.43 HIPAA Compliance
Although the Plan is exempt from certain requirements of HIPAA, the TPA must comply
with all applicable requirements of HIPAA, including, but not limited to, the Administrative
Simplification and Security Rule provisions.
2010 State and School Employees Health Insurance Management Board TPA RFP
Page 28
3.44 Certificate of Creditable Coverage
The TPA is responsible for:
a.
b.
c.
Issuing certificates of creditable coverage to covered participants and their
dependents when they cease to be covered under the Plan
Receiving certificates of creditable coverage for new participants and adjusting preexisting periods accordingly
Notification to participant regarding remaining pre-existing limitation period
3.45 Retrieval and Distribution of Records
Data contained on tapes, discs, files, batch files, and other records pertinent to the Plan,
unless not otherwise prohibited by law, are the property of the Board and must be made
capable of separate retrieval and distribution and be readily available to the Board on
request. The TPA’s physical security of all such records must comply with or exceed all
applicable state and federal legal requirements. The TPA must have in place current
procedures documenting its security and off-site storage.
3.46 Claims and Performance Reviews
The Board, at its own expense, contracts with an independent third party vendor to conduct
annual claims and performance reviews of the TPA. In addition, the operations of the TPA
relative to the Plan are included in annual audits conducted by the State Auditor’s Office.
The TPA must agrees that upon at least forty-eight (48) hour notice by the Board to the
TPA, the Board has the right to audit all records maintained by the TPA relative to the
TPA’s performance. The Board maintains the right to perform financial, performance and
other special audits on records maintained by the TPA during regular business hours. The
TPA will make available all records, as defined by the selected auditor, for review at no cost
to the Board. This does not preclude the auditing of other services or additional claims. Any
errors detected via the audit will be addressed and corrected in a timely manner by the TPA.
Any claim processing error will be adjusted to the proper account.
3.47 Medical Consultation
The Board may contact the TPA on an as needed basis for the medical advice/expertise of
physicians and/or nurses to assist the Board in making benefit determinations. This medical
consultant role will include providing medical necessity opinions based on up-to-date
medical literature and review of medical records in order to make a medical necessity and/or
pre-existing determination. The TPA must administer medical consultation determinations
in accordance with all regulations required by PPACA.
3.48 Standard/Ad Hoc Reporting
The TPA must furnish standard reports in a form and content approved by the Board. These
reports will be provided, at the Board's request, in a hard copy and/or electronic media
format. Additionally, the TPA will provide ad hoc reports at the Board's request. The TPA
will provide the Board, for the Board's approval, the time and cost for the development of
custom reports prior to the development of the report. The cost of custom reports will be
based upon the number of hours required for programming at the hourly programming cost
indicated in Section 5 Financial Exhibit. At a minimum, the TPA will provide the
standard reports as described in Appendix M.
2010 State and School Employees Health Insurance Management Board TPA RFP
Page 29
3.49 Benefit Fairs
The TPA agrees to participate in approximately fifty (50) benefit fairs per year to educate
Plan participants.
3.50 Transition of Services:
The selected TPA will be responsible for coordinating with the existing TPA to transition
services previously approved by the existing TPA.
3.51 SAS 70 Type II Audit:
The selected TPA must agree to undergo a SAS 70 Type II audit annually at its own
expense, with such resulting reports to be provided to the Board upon completion of said
audits. To the extent the selected TPA utilizes a third party vendor(s) for any applicable
component of the TPA services to be provided to the Board, as described within this RFP or
any resulting contract, the TPA must ensure that the third party vendor(s) likewise undergo
a SAS 70 Type II audit annually, and provide to the Board copies of resulting reports at no
expense to the Board.
2010 State and School Employees Health Insurance Management Board TPA RFP
Page 30
4
Questionnaire
4.1 GENERAL QUESTIONS:
1.
State the full name and home office of your organization.
2.
Describe your organizational structure, including your main and branch offices.
Indicate whether it operates as a corporation, partnership, or individual. If it is
incorporated, include the state in which it is incorporated. Please provide a
schematic of your organization’s structure.
3.
List the names and occupation of those individuals serving on your organization’s
Board of Directors.
4.
List the name of any entity or person owning 10% or more of your organization.
5.
Describe any ownership or name changes your organization has been through in the
past three (3) years. Are any ownership or name changes planned?
6.
List any ownership interest your company has in any health care facility, provider
or PBM and describe the relationship.
7.
Is your organization licensed or authorized to do business in the State of
Mississippi?
8.
Provide the name, title, address, e-mail address, phone number, and fax number of
the contact person for this RFP.
9.
State if the proposed account manager, any officers or principals and/or their
immediate families are, or have been within the preceding 12 months, employees of
the State of Mississippi.
10.
Indicate the month and year your organization was established.
11.
Indicate the month and year your organization began providing Third Party Medical
Claims Administration Services.
12.
Please provide the location of the office in which you propose to place this
business.
13.
Does your proposal assume a joint venture with any other organization(s)? If so,
specify your role and those of the other organization(s).
14.
What percent of all claims are processed within 30 working days of receipt, for
calendar year 2010?
2010 State and School Employees Health Insurance Management Board TPA RFP
Page 31
15.
Please provide the following for the calendar year 2010:
a.
b.
Financial accuracy as a percent of total claims dollars paid (total under and
over payments, do not net these amounts);
Coding accuracy as a percent of total claims submitted.
16.
Please provide the average number of employees for company for calendar year
2010.
17.
State law requires that the TPA shall cooperate with all other contractors of the
Board in the on-going coordination of health plan services and in any transition of
responsibility. Confirm you will comply with this requirement.
18.
State if you currently provide any services, directly or indirectly, to the Board
members, or any of the following:












Blue Cross & Blue Shield of Mississippi
Thomson Reuters (Healthcare) Inc.
PricewaterhouseCoopers, LLP
WM. Lynn Townsend, FSA, MAAA
ActiveHealth Management, Inc.
Minnesota Life Insurance Company
Advanced Health Services, Inc.
Cavanaugh Macdonald Consulting, LLC
Claims Technologies, Inc.
WebMD Health Services Group, Inc.
Catalyst Rx
State and School Employees Health Insurance Management Board Members:
Kevin Upchurch (Chairman) – Executive Director, Department of Finance and
Administration; Dr. Tom Burnham – State Superintendent of Education; Liles
Williams – Chairman, Workers’ Compensation Commission; Mike Chaney –
Commissioner, Department of Insurance; Dr. Hank Bounds – Commissioner,
Institutions of Higher Learning; Pat Robertson- Executive Director, Public
Employees’ Retirement System; Lynn Fitch- Director, State Personnel Board; Dr.
Eric Clark- Executive Director, State Board of Community and Junior Colleges;
Christopher Burkhalter – Bickerstaff, Whatley, Ryan & Burkhalter Consulting
Actuaries; Larry Fortenberry – President, Executive Planning Group; The
Honorable Alan Nunnelee – Chairman, Senate Appropriations Committee; The
Honorable Johnny Stringer – Chairman, House Appropriations Committee; The
Honorable Walter Robinson, Jr. – Chairman, House Insurance Committee; and
The Honorable Eugene Clarke – Chairman, Senate Insurance Committee.
If your firm currently provides services to, or receive services from, one of
these vendors, provide a full description of services provided.
19.
Please indicate the total number of participants covered by your TPA services as of
12/31/10.
2010 State and School Employees Health Insurance Management Board TPA RFP
Page 32
20.
For the office in which you propose to place this business, please indicate the
number and types (e.g. customer service representatives, claims processors) of new
staff you would need to hire to implement the requested services for the Board.
21.
For the office in which you propose to place this business, please indicate the
following:
a.
b.
Ratio of claim processing staff per 1,000 members covered under the
various plans
Organizational structure of the unit (e.g. supervisor, manager, administrator,
clerical)
4.2 CUSTOMER SERVICE
22.
You are required to provide an exclusive customer service unit and an exclusive
customer service toll-free number exclusively for Plan participant inquires.
Confirm that you will agree to this requirement. Describe your customer service
department. Include organizational structure, hours and days of operation, staffing,
and training. Indicate how you would know if the number of incoming lines is
insufficient and the steps you would take to correct the problem. Please confirm
whether you are able to provide reports on call availability, answering speed, onhold time and abandonment rates exclusively for the Plan. How are after-hours
calls handled?
23.
How does your customer service unit coordinate with the customer service units of
the Plan’s other vendors (e.g. Pharmacy Benefit Manager, Medical Management
Administrator)? Can you provide warm transfers?
24.
You are required to provide a separate customer service toll free number
exclusively for provider inquires. Confirm that you will agree to this requirement.
Describe your provider customer service department. Include organizational
structure, hours and days of operation, staffing, and training. Indicate how you
would know if the number of incoming lines is insufficient and the steps you would
take to correct the problem. Please confirm whether you are able to provide reports on
call availability, answering speed, on-hold time and abandonment rates exclusively for
the Plan. How are after-hours calls handled?
25.
Confirm that your provider customer service staff will provide the following:
a.
Assisting providers with questions concerning eligibility status
b.
Assisting providers with claims payment procedures for the coverage and
electronic submission of claims in accordance with HIPAA EDI standards
c.
Handling provider complaints and grievances
d.
Educating providers as to their responsibilities under the Plan
e.
Educating providers as to covered medical services, excluded medical
services and benefit limitations
2010 State and School Employees Health Insurance Management Board TPA RFP
Page 33
26.
The TPA is responsible for maintaining an automated phone system for providers
for verification of participant eligibility, benefit summaries, deductible and coinsurance maximum accumulation amounts and claims status. This automated must
be available twenty four (24) hours, seven (7) days a week. Please describe the
automated phone system your organization will maintain to meet this requirement.
27.
The TPA is responsible for designing, printing and distributing customized
brochures, posters, and forms, with the Board’s approval, as necessary and required
to install and administer the services to Plan participants, employer units, and the
Board. Confirm that your proposal provides a fee quotation for supplying these
materials, including the cost of mailing any communication materials directly to
participant home addresses, directly to employer units, and the Board.
28.
Does your organization conduct provider satisfaction surveys? If so, in your most
recent survey what percentage of providers was dissatisfied overall?
29.
You are required to assign an exclusive customer service representative to the
Board’s account. Please confirm that you agree to this.
30.
You are required to assign a dedicated (but not necessarily exclusive) account
manager to participate in activities relative to all aspects of the contract between the
Board and the TPA. Please confirm that you agree to this. How many additional
clients does this dedicated account manager routinely handle? What is the average
size (in covered lives) of the accounts?
31.
Assuming that your organization is awarded the TPA contract, will you agree to
activate an exclusive toll-free telephone number by November 1, 2011?
32.
How are medical providers alerted about new client accounts? How do you plan to
educate providers regarding your policies and procedures?
33.
Please provide the following telephone information for calendar year 2010. If your
organization has separate phone lines for participants and providers, please provide
information for both units. Provide documentation substantiating your responses.
a.
b.
c.
34.
Total abandonment rate for the Customer Service unit.
Average hold time for the Customer Service unit.
Average speed of answer for calls received in the Customer Service unit.
Identify the individual in the following positions within your organization and
supply a resume including each person’s credentials and tenure with the company.
If these positions are within each service center, please provide the names and
resumes for the service center you are proposing to place this business.



Executive Officer
Medical Director
Service Center Medical Director
2010 State and School Employees Health Insurance Management Board TPA RFP
Page 34




Operations Director
Account Executive
Dedicated Customer Service Representative
Claims Supervisor
35.
What are your hours of operation in Central Standard Time?
36.
Describe your capabilities for tracking participant and provider inquiries or
complaints and reporting this information to DFA on a monthly or quarterly basis.
Please provide a sample report with your proposal.
37.
If a provider is not participating in a network, what is your customer service process
for advising the Plan participant and provider of the out of network status and
channeling Plan participants to network providers?
38.
Describe how your customer service representatives trigger corrections to claims or
activate the claim re-processing functions based on discussions/clarifications with
members, providers, or DFA. Is this process on-line (real time-system input and
correction) or does the re-processing function require that the customer service
representative submit a correction form or perform other manual processes?
39.
What services are available to accommodate special populations, including (1) nonEnglish speaking, (2) hearing impaired, (3) visual impaired, and (4) the elderly?
40.
You are required to generate new or replacement ID cards and distribute the ID
cards directly to the Plan Participant’s home address for (1) the initial enrollment of
the Plan, (2) future new hires, (3) Plan participants who change coverage category
(e.g. single to family) and (4) replacement of lost cards. Plan participants with
single coverage should receive one (1) ID card; Plan participants with dependent
coverage should receive two (2) ID cards. The information to be printed on each ID
card will include, at a minimum, the Plan Participant’s name and identification
number, Plan name, the TPA name and toll free customer service line number, in
the Board’s specifications. Confirm that your proposal provides a fee quotation for
all costs related to ID cards, including the cost of mailing the ID cards directly to
participant home locations.
4.3 CLAIM PROCESSING
41.
Do you propose to assign a dedicated or exclusive unit of claim processors for the
Board's account? If the dedicated unit will have responsibilities for other client
accounts, please indicate the number of other clients served, the other clients
employee size, and the geographic location of the other clients.
42.
Please describe the organizational structure of the proposed claim processing unit
which will be assigned to the Board’s account (e.g. supervisor, manager,
administrator, clerical) and the number of claim adjudicators that will be assigned to
the Board account by job class.
2010 State and School Employees Health Insurance Management Board TPA RFP
Page 35
43.
Do all persons entering data/processing claims have the authority to pay COB,
subrogation, Medicare, and high dollar claim amounts, or does the authority level
vary with experience? Do you segment your claim processing functions by benefit
specialties?
44.
Please indicate any maximum claim amount/limits which apply by staff level and
any system/manual processes that trigger supervisory approval or internal/external
audits.
45.
Are any of your claim adjudicators on a "quota system" for processing claims? If
so, please describe.
46.
Confirm that, upon termination of the contract you will adjudicate and process all
claims with service dates prior to the termination date of the contract that are
received within 180 days after the termination date. Confirm that your proposal
provides a fee quotation for all costs related to run-out claims administration.
4.4 PLAN DESIGN
47.
Can your organization administer the plan design as outlined in the Plan Document
located in Appendix B? Identify any Plan design provisions that you cannot
administer. Can your organization administer the health and wellness guidelines
located in Appendix N? Identify any wellness benefit design provisions which will
require custom programming and/or manual processing by the claims adjudicator
48.
Identify any Plan design provisions which will require custom programming and/or
manual processing by the claims adjudicator.
49.
For each of the following processes please indicate with an (X) whether your claims
system handles the task in an automated manner (A), uses processor review/manual
intervention (PR), or is not routinely checked (NC).
Process:
Cross references family deductible accumulations when married
employees are both covered under the Plan
Checks total charges against total payments
Checks for duplicate charges
Compares number of inpatient hospital days on each claim against
admission and discharge dates
Assures services are provided within the employee's eligibility date
and maintains breaks in active service.
Recognizes historical benefit maximums (employees may have
multiple periods of employment with the State)
Identifies excess "usual, customary and reasonable" charges
(R&C) for all procedures
2010 State and School Employees Health Insurance Management Board TPA RFP
A
PR
Page 36
NC
Identifies potential pre-existing conditions
Verifies that a provider is licensed to perform the type of
procedure billed
Reconciles the diagnosis code to the procedure and sex code for
consistency
Computes benefit year deductibles
Integrates in-network deductible accumulations with out-ofnetwork deductibles requirements
Identifies potential COB situations
Verifies out-of-pocket
Reviews age limits for eligibility or special coverage limits (e.g.
wellness benefits)
Determines coinsurance levels
Identifies unbundling of services
Identifies up-coding of services
Identifies obsolete or invalid codes
Identifies ineligible services
Applies multiple surgery guidelines
50.
Can a claims examiner "override" the system to process unique circumstances
attributed to a claim? When, and under what circumstances?
51.
In the event your indicated “uses processor review/manual intervention (PR)” for
any of the above processes, describe how the system "flags" the claim and the
resulting workflow to re-activate claim processing functions.
52.
In the event any of the above processes are not routinely checked, describe how you
propose to administer the Plan’s design parameters.
53.
Does your claim system allow certain employees and/or benefit provisions to be
"flagged" for processing based on instructions from the Medical Management
vendor and/or DFA? Please describe the "flagging" process.
54.
What percentage of your current book of business represents claims which are
electronically filed by providers versus traditional paper processing?
55.
Provide flow charts of the claims adjudication process. Separate flow charts should
be provided for paper and electronic claims. Indicate each manual or computer
system interface from the time the claim is received in the mail room until
processed and an EOB is released.
56.
Please indicate whether your claim processing functions include any of the
following:
a.
b.
Electronic imaging of paper claims
On-line (real-time) claims processing
2010 State and School Employees Health Insurance Management Board TPA RFP
Page 37
c.
d.
e.
f.
Batch (over-night) claims processing
Electronic data interchange (EDI)
Microfilm/digital claim copies
Microfilm/digital member correspondence
57.
Provide your definition of a "clean" claim. How many people will physically handle
a "clean" claim from receipt in the mail room to payment? Differentiate between
paper and electronic claims.
58.
Describe the method of tracking claims, member correspondence, EOBs or other
requested adjustments and relating the adjustments to specific claims.
59.
Confirm that your organization maintains a system for tracking claims received,
processing status, pending status, and member correspondence.
60.
You are required to provide, at your own cost, the Board on-line look-up access to
claim/membership/eligibility information. On-line access must allow for inquiry
only including historical eligibility and claims information. Will this system also
allow the Board to have on-line authority to add policy exceptions and/or add
information to employee profiles? Please provide specific information regarding
on-line capabilities and confirm that your proposal includes the cost for this service.
Please indicate any additional charges that may apply if the Board elects on-line
access for additional staff.
61.
Provide a sample of proposed or currently used forms or form letters which may be
mailed to a member/provider to elicit additional information when the claim form
or medical information is incomplete for claim adjudication. Annotate the sample
to show the purpose of the correspondence.
62.
To what degree will your organization customize the various standard
member/service correspondence, including system generated correspondence, to
meet the Board's needs and style of communication?
63.
Describe how your system edits a claim to determine whether the claim is "clean"
or will require additional information (e.g. does the claim reject at the first
incomplete data field or is the entire claim reviewed and all incomplete information
identified?
64.
How many diagnoses can your system maintain for a given claim?
65.
Describe your claims adjudication process in terms of the following (please address
each item separately):
a.
What data is edited against the eligibility file to verify coverage of the
employee? The dependent?
2010 State and School Employees Health Insurance Management Board TPA RFP
Page 38
b.
c.
d.
66.
What edits are in place to compare the number of inpatient hospital days
against admission and discharge dates supplied by the medical management
vendor?
What edits are in place to review age limits for eligibility or special
coverage requirements (e.g. wellness benefits)?
What edits are in place to detect direction of pay errors (i.e., payments
intended for providers that are sent to patients or vice versa)?
Please address the following issues relative to allowable charge information for outof-network charges:
a.
b.
c.
d.
e.
Source of allowable charge data
What is the frequency that data is updated?
What flexibility does the Board have in customizing allowable charge
amounts?
What allowable charge data do you use for anesthesia? For durable medical
equipment? For injectibles? For orthopedic supplies, prosthetics, etc.? For
assistant surgeons?
How do you develop allowable charges for low volume or rare codes?
67.
The Board requires that all benefit payments in excess of $2,500 be pended for
verification that the claim form authorized payment to the participant. Please
indicate that you can comply with this requirement.
68.
For what length of time are detailed claim records for a member maintained
"on-line"? Describe how detailed claim records are stored and accessed when the
information is no longer "on-line". What is the turn-around time for retrieval for
stored information?
69.
What is your payment cycle (daily, weekly, etc.) for providers and participants?
70.
Describe the process used to evaluate claims for medical necessity.
71.
Describe any system edits for identifying claims that are suspected for excessive
number of units, visits or days. Once identified, what process is followed and by
whom for further review?
72.
Describe in detail your process for inspecting claims for pre-existing conditions and
obtaining additional information from the participant and/or the provider to make a
determination.
73.
What is your process for identifying potential cosmetic, investigational or
experimental treatments or procedures?
74.
How is your organization notified when a procedure, previously determined to be
experimental, is approved for routine use?
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75.
Describe how your system applies penalties for medical management
noncompliance. Provide an example using the existing penalties as described in the
Plan Document located in Appendix B.
76.
How does your system handle penalties for medical management noncompliance
where a DRG or per diem reimbursement pricing arrangement is in place?
77.
Are any types of services or procedures required to be aggregated into one code by
the processing system?
78.
What edits are currently included in your software system to identify the following
(please answer each individually)? Describe any manual interventions performed
by the claims examiner.
a.
inappropriate medical services
b.
fraud, abuse or over-utilization of services
c.
inclusive or incidental diagnostic procedures
d.
unbundled medical or surgical procedures
e.
multiple surgery modifier
f.
upcoding
g.
duplicate bills
h.
unnecessary assistant surgeon
i.
“never” events
79.
Due to potential time delays associated with the existing eligibility reporting
process, do you have a standard report which captures claims data for members who
incur claims and receive claim reimbursement after their termination with the Plan?
4.5 COORDINATION OF BENEFITS
80.
Describe the process for collecting information regarding other insurance
information. Include where this data is stored and how the claims processing
system accesses the information for proper claim payment.
81.
What sources of information are used by your organization to determine other
coverage, other than the employee's statement and the claims history/eligibility file?
82.
Does your claims system maintain other insurance information for each of the
following members?
a.
b.
c.
d.
83.
Employee only
Individually, by covered participant including each dependent
Employees who are Medicare eligible
Dependents who are Medicare eligible
How many occurrences of "other insurance" information can be stored for each
employee/dependent on your system simultaneously?
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84.
When new or requested COB information is received, describe the process for
updating the information on your system. Are pended claims re-activated by a
manual process or automatic by the system?
85.
Describe your process for handling COB when a conflict exists between
information on your system and claim form.
86.
What is the maximum length of time a claim is pended for COB information before
the claim is processed without payment?
87.
Review the Plan's requirements for COB processing as described in the Plan
Document located in Appendix B. Please confirm that you can administer the
Plan’s COB provisions.
88.
Can your system allow the automatic electronic transfer of claims from Medicare
for secondary coverage payments?
89.
The Plan assumes any retiree eligible for Medicare has both Parts A and B,
regardless of whether the retiree has selected Part B or not. Can your system
estimate Part B reimbursement when adjudicating a claim in which the Plan is the
secondary payor? The Plan Document located in Appendix B further describes the
Plan’s Medicare COB provisions.
90.
Do you provide written notice to retirees when they become age 65 that their
coordination with Medicare will impact the coverage reimbursements under the
Plan?
91.
Do you notify participants in writing when they become age 65 that Medicare
coverage is available to them?
4.6 THIRD PARTY LIABILITY
SUBROGATION)
(WORKER'S
COMPENSATION
AND
92.
Describe the process for identifying potential workers' compensation claims.
93.
Are there diagnoses that automatically suspend claims due to suspect workers'
compensation?
94.
Describe how subsequent claims for the same workers' compensation condition will
be handled.
95.
Describe the process of identifying suspect third-party liability claims, such as
automobile accidental injury, injuries in the home or malpractice.
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96.
Describe your legal services available for services relative to disputed
claims/litigation/subrogation. Confirm that the cost for this service is included in
your administration fee.
97.
The Plan's current rights of subrogation are described in the Plan Document located
in Appendix B. Describe your process of establishing the Plan's right of
subrogation. Include sample correspondence.
98.
Do you use external resources to pursue subrogation? If so, please describe and
confirm that the cost for this service is included in your administration fee. Please
list the external resource, length of your relationship and your evaluation of the
external resource's performance.
99.
How are claims handled during the process of establishing the third-party liability?
Do you pay the claim and then pursue recovery or pursue before paying?
4.7 NETWORK PROVIDER REIMBURSEMENTS
100.
Provider reimbursement methodologies include diagnosis-related group (DRG), fee
schedules, percent of charge (POC), per diem, ambulatory payment group (APG)
and ambulatory payment class (APC). Confirm that your claim processing system
can accommodate each of these arrangements. Indicate the DRG grouper used and
how often it is updated.
101.
Describe the main features of your provider file database and the interface which
occurs with the claims processing function.
102.
Describe the processing functions which are used to validate an in-network
provider.
103.
Describe how your system links in-network providers to the appropriate fee
schedule.
104.
Describe how your system links a provider with:
a.
separate billing offices
b.
multiple providers in the same group
c.
providers in a group practice and/or individual practitioners
d.
individual physicians and their affiliation with multiple physician clinics.
105.
Describe how your system will track contract percentage discounts, per diem rates,
and DRG reimbursements to be used for payment of claims.
106.
Does your system have the ability to pay providers electronically?
107.
Do you make monetary adjustments on a provider's payment voucher to recoup
claim overpayments which may have occurred previously? Are there any
restrictions to completing this process? Please describe any restrictions noted.
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108.
Will you agree to administer prompt payments to providers based on medical
management negotiations or network agreements? Fully describe your prompt
payment process.
109.
How are direction of pay errors corrected? Will you agree to make the Board whole
when an error made by your organization results in a direction payment error?
4.8 MEDICAL REVIEW AND APPEALS
110.
Describe your process for updating clinical protocols including new procedures or
new technology/pharmacology and the frequency of updates. Describe how
updated information is communicated to the medical review staff?
111.
Describe your protocol to distinguish medical necessity from administrative benefit
denials.
112.
For the purpose of this question, the term “complaint” is defined as a written or
verbal expression of dissatisfaction. What was the total number of complaints filed
with your company per 1,000 enrollees in the most recently available 12-month
period? What was the total number of complaints filed per 1,000 enrollees in the
prior 12-month period? Please include in your response the time period upon which
your answer is based.
113.
Please describe your appeals process. Specifically, your response should indicate
how first level appeals are managed, who is responsible for making the
determination and their respective industry experience/background and the timing
for issuing a response. Assuming the first level appeal is not favorable to the
participant, what procedures and processes would apply for a second appeal?
114.
The Board requires that review of the first level written appeal involving a medical
matter to be conducted by the medical review staff which includes a licensed RN or
the staff physician. Confirm that you agree to this requirement.
115.
The appeals process used by DFA relating to medical claims is described in the
Plan Document located in Appendix B. Please review this process and confirm
your willingness to implement this process.
116.
The TPA is required to maintain contracts with a minimum or three (3) independent
review organizations (IRO) that are accredited by URAC or by a similar nationallyrecognized accrediting organization to conduct external reviews as required by
PPACA. Confirm that you agree with this requirement. Confirm that your proposal
provides a fee quotation for independent reviews.
117.
The TPA is required to administer appeal and grievance procedures in accordance
with all regulations required by PPACA. Please confirm your agreement with this
requirement.
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118.
For your IROs provide the following:
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
Full legal name.
Headquarters address.
The name, title, mailing address, telephone number and facsimile number of the
contact person for this proposal.
Accreditation (URAC or a similar nationally-recognized accrediting
organization to conduct external reviews as required by PPACA)
A description of the services to be provided.
length of relationship with this subcontractor
your evaluation of the subcontractor's performance
As of the proposal due date, the number of years of experience in providing
similar service to those which they will be performing under this contract for
other clients.
As of the proposal due date, the total covered population, in terms of number of
covered lives (includes active employees, retirees, COBRA, and dependents)
serviced by the Subcontractor.
Indicate whether you currently have a current contract with the subcontractor.
If so, provide copies of such agreements.
119.
What percentage of all claims appealed within your organization proceeded to the final
level of internal appeal?
120.
How are the patient and provider notified of the outcome of an appeal?
121.
The Board will retain final determination for appeals which are not favorable to the
participant/provider.
Confirm that this requirement is acceptable to your
organization.
4.9 QUALITY ASSURANCE:
122.
Describe your internal quality control procedures for assuring accurate claims
payment.
Include an explanation of sampling techniques used by
supervisory/management for the review of work performed by each claims
adjudicator
123.
Describe internal cash controls, including handling adjustments for claims, returned
drafts, voided drafts and stale dated drafts.
124.
Describe your internal audit and quality control procedures. Provide a copy of your
formal policies and procedures.
125.
Has your organization had a SAS 70 Type I or Type II audit? For what period?
Provide a copy of the audit report.
126.
Do you have in place a process to detect and investigate suspected fraud? If so,
please describe and provide a copy of your formal policies and procedures.
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127.
Do you perform hospital DRG and physician bill audits for hospital stays,
outpatient procedures, etc. internally or subcontract with an independent firm?
Please describe the parameters for performing each of these audits. Confirm that
the cost of performing provider bill audits is included in your administration fee.
If you subcontract this function, list:
a.
b.
c.
d.
e.
f.
g.
h.
i.
Full legal name.
Headquarters address
The name, title, mailing address, telephone number and facsimile number of the
contact person for this proposal
A description of the services to be provided
length of relationship with this subcontractor
your evaluation of the subcontractor's performance
As of the proposal due date, the number of years of experience in providing
similar service to those which they will be performing under this contract for
other clients
As of the proposal due date, the total covered population, in terms of number of
covered lives (includes active employees, retirees, COBRA, and dependents)
serviced by the subcontractor
Indicate whether you currently have a current contract with the subcontractor.
If so, provide copies of such agreements
128.
Provide your staff turnover rate by all operations positions involved in third party
medical claims administration for the most recent 24-month period for your
company as well as the office for which you propose to place this business.
129.
Does your company conduct satisfaction surveys for participants? If so, provide the
results of the most recent Plan participant satisfaction survey.
130.
Who conducts satisfaction surveys on your behalf?
telephonically or via mail?
131.
Indicate the percentage of members who responded during the last completed survey
that they were at least “satisfied” with your organization.
132.
Would you be willing to customize a satisfaction survey for the Plan? Confirm that
your proposal includes a fee quotation for customizing, mailing, compiling and
reporting results to the Board.
Are surveys conducted
4.10 EXPLANATION OF BENEFITS
133.
Please provide a sample explanation of benefits (EOB) form. Confirm that your
EOB is compliant with PPACA.
134.
Please describe your capability for participants and providers to access, download,
and print EOBs on-line.
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135.
Will you allow the Board to customize EOB messages?
136.
The claims administrator must prepare and keep on file an EOB for each claim
processed, including both electronic and paper claims. At a minimum, the EOB
must include: name and address of TPA, toll free number for TPA, participant’s
name and address, participant’s identification number, patient's name, provider
name, claim date of service, type of service, total charges, discount amount, allowed
amount, excluded charges, amount applied to deductible, co-payment/coinsurance
amount, total patient responsibility, total payment made and to whom. Confirm that
you will comply with this requirement.
137.
Does your system provide an EOB to a provider if payment is made to the
participant or there is zero payment made by the Plan (all charges applied to
deductible or denied as non-covered)?
4.11 ELIGIBILITY AND PREMIUM BILLING
138.
Section 3 Scope of Services outlines the transfer process and service requirements
for eligibility file maintenance and direct bill premium statements. Confirm that
your proposal includes the cost for these services. Explain the process for premium
statement reconciliation when additions or deletions are retroactive.
139.
Using Appendix O – SPAHRS 834 file layout information, please describe your
ability to meet requirements for receiving SPAHRS electronic enrollment data. At
a minimum, your description must include:
a.
b.
c.
your ability to handle codes used by SPAHRS
other processing options which may be available
code values used in your system for processing enrollment information
140.
Using Appendix P Confirmation file layout, describe your ability to meet
requirements for transmitting confirmation data to SPAHRS. Describe other
processing options which may be available.
141.
SPAHRS currently processes overnight (Monday through Friday) sending and
receiving files of employee enrollment and confirmation information. Please
describe your ability to meet this requirement including the daily batch processing
of electronic enrollment data.
142.
SPAHRS receives a daily error file of enrollment information located in Appendix
Q error file layout. Please describe your ability to meet this requirement. At a
minimum, your description must include the process for error correction and other
error file handling options which may be available.
143.
The current process includes a hold file process, Appendix G hold file layout, used
for transactions that cannot be accepted or rejected until further information from
the employer unit has been received. The TPA is required to allow for transactions
2010 State and School Employees Health Insurance Management Board TPA RFP
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to be placed in a hold status. Describe your process for hold transaction resolution
as well as other hold processing option that may be available.
144.
Refer to Appendix G, hold file layout, used for transactions that cannot be accepted
or rejected until further information from the employer unit has been received. The
TPA is required to allow for transactions to be placed in a hold status. The TPA is
also required to provide on-line access to the hold file to the Board to approve/reject
transactions and return such decisions to the TPA via electronic means. Please
describe your ability to meet this requirement. Please specify all hardware and
software required to implement this process including software releases and
operating system service packs/patches required.
145.
Describe any data conversion processes that may be required to load the Board’s
specific employee enrollment data in their system. At a minimum, your description
must include:
a.
b.
c.
any required file layouts
any enrollment code conversions which may be required
a detailed estimate of hours required for the conversion process using the
enrollment information located in Appendix O.
146.
You are required to provide a proposed “Acceptance Test Plan” (ATP) prior to
acceptance testing of the system by the Board including events, sequences and
schedules, to include stress testing and regression testing, required for acceptance of
the system. You must also allow for a final acceptance-testing period of up to 30
calendar days in accordance with the work plan delivery schedule. Confirm your
agreement to this requirement.
147.
As an attachment to your proposal, include a high-level project plan for the full
scope of implementation services for SPAHRS electronic enrollment described in
this RFP. Your project plan should demonstrate a suggested overall approach,
sequence, required Board staff, and dependencies for accomplishing the Board’s
objectives as outlined in this RFP.
148.
Please acknowledge that any information system proposed, developed, or modified
that disseminates, in any form or manner, information or material that contains the
Social Security Number of an individual, has mechanisms in place to prevent the
inadvertent disclosure of the individual’s Social Security Number to members of the
general public or to persons other than those persons who, in the performance of
their duties and responsibilities, have a lawful and legitimate need to know the
individual’s Social Security Number as required by Section 25-1-111 of the
Mississippi Code Annotated.
149.
Confirm if you are able to meet the Board’s requirements for VPN connection to
State VPN concentrator for FTP as well as comply with other aspects of the ITS
security policy. Refer to Section 3.23, Enrollment and Eligibility of this RFP.
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150.
Mississippi’s Accountability System for Government Information and
Collaboration (MAGIC) is the State’s Enterprise Resource Planning (ERP) project
scheduled to replace the State’s accounting system SAAS in 2013. The next phased
implementation will replace the human resource and payroll system SPAHRS in
2014. Confirm your understanding that the selected proposer must migrate to
MAGIC once it is implemented.
151.
Please describe any online reporting facilities available for administrative and
employer unit use, including access security and setup.
152.
Please specify all hardware and software required to implement the SPAHRS
process including software releases and operating system service packs/patches
required.
153.
You are required to provide an electronic enrollment process for those employer
units not using the SPAHRS. Please specify all hardware and software required to
implement the electronic enrollment process including software releases and
operating system service packs/patches required.
154.
You are required to provide an electronic enrollment process to the Board for the
addition of eligible retirees. Please specify all hardware and software required to
implement the electronic enrollment process including software releases and
operating system service packs/patches required.
155.
Please describe your ability to meet the electronic enrollment requirement including
the processing of electronic enrollment data.
156.
Please describe your process for resolving electronic enrollment transactions that
cannot be accepted or rejected until further information from the employer unit has
been received.
157.
The monthly update of member eligibility may consist of changes in coverage type
or miscellaneous data. Please describe how your system would handle the
following:
a.
b.
c.
158.
changes in coverage category (e.g. single, family) which will occur at some
date in the future
changes in coverage category (e.g. single, family) which will be retroactive
and impact prior claim payments
change in demographic information (e.g. address changes, names)
Confirm that you can accommodate the current PERS billing report file layout in
Appendix K of this RFP. Note any exceptions or concerns you may have with this
file layout. Note any additional data fields you would require to accommodate this
file layout. If you currently interface with a retirement system for billing purposes,
please provide a client reference including client contact name, title, address,
telephone and fax number. Confirm that your proposal includes the cost of the
interface with PERS.
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159.
You are required to maintain adequate personnel for purposes of maintaining
eligibility and premium billing/reconciliation functions. Indicate the number of
staff you propose to perform these functions.
4.12 SYSTEMS, DATA TRANSFER, AND REPORTING CAPABILITIES:
160.
How many Information Systems personnel are employed by your company?
161.
Are system programmers comprised of in-house staff or contracted professionals?
162.
Please provide a current organization chart and break down of Information Systems
personnel by job classification.
163.
What is the average percent of employee turnover in your Information Systems
Organization?
164.
How many claims are processed by your Information System yearly?
165.
For reporting to clients, please provide samples of the reports that would provide
those required elements listed in Appendix M. If samples are not available, please
indicate if reports can be created prior to implementation of this contract.
166.
Other than the report information listed in listed in Appendix M, list and describe any
other claim/management reports you are able to provide regularly at no additional
charge and the frequency with which this information can be provided. Provide
samples of each report.
167.
Does your system provide web-based reporting tools that allow the client to view
and print their reports? If so, can these reports be downloaded to Excel? How
many months of reports are maintained on-line? Also, explain what type of security
is offered to protect the information. If so, please describe reporting capabilities,
claim look-up functions, standard report writers and associated cost assuming six
users.
168.
Describe your capability to produce ad hoc reports and associated programming
charges.
169.
Do you sell or report any data from your clients, either specifically or in aggregate,
to any organization? If so, please disclose these arrangements in detail.
170.
Can provider networks be loaded within your system? Describe how your system
discerns network providers from out of network providers.
171.
Do you have a contract and/or procedures manual for each staff position?
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172.
Do you have any subcontractors that will handle the Plan’s PHI? If yes, does your
contract with those subcontractors contain privacy and security provisions?
173.
When an entity (e.g., providers) or an individual makes an inquiry about an
individual’s eligibility for benefits, how is privacy protected
174.
Have you conducted an analysis of the risks and vulnerabilities to protected health
information in your system?
175.
Fully describe your plans for the upcoming ICD-10 conversion. How will this
conversion impact your current system(s)?
176.
Fully describe your plans for implementing HIPAA 5010 including, but not limited
to, claims, remittance, eligibility, and claims status requests and responses.
177.
Network fee schedules are updated as needed. Please indicate the lead time
necessary to load this information in your system for processing and describe your
process to load and verify that the fee schedules have updated successfully.
178.
Can your system accommodate multiple provider reimbursement schedules in order
to correctly re-price and process claims incurred before and after a provider fee
schedule change based on the date medical services were provided?
179.
You are required to produce an electronic billing file containing all employer unit
statements for the Board. The electronic billing file is distributed to employer units
by the Board. The current electronic billing file layout is located in Appendix I of
this RFP. Note any exceptions or concerns you may have with this file layout.
Note any additional data fields you would require to accommodate this file layout.
If you currently provide an electronic billing file as described in this RFP, please
provide a client reference including client contact name, title, address, telephone
and fax number. Confirm that your proposal includes the cost of providing an
electronic billing file.
180.
You are required to interface with the Plan’s data management vendor. Confirm that
you can accommodate the current data management vendor data layout file
provided in Appendix R of this RFP. Note any exceptions or concerns you may
have with this file layout. Note any additional data fields you would require to
accommodate this file layout. If you currently interface with a data management
vendor, please provide a client reference including client contact name, title,
address, telephone and fax number. Confirm that your proposal includes the cost of
the interface with the Board’s current data management vendor.
181.
You are required to interface with the Plan’s pharmacy benefit manager. Confirm
that you can accommodate the current pharmacy benefit manager data layout file
located in Appendix S of this RFP. Note any exceptions or concerns you may have
with this file layout. Note any additional data fields you would require to
accommodate this file layout. If you currently interface with a pharmacy benefit
2010 State and School Employees Health Insurance Management Board TPA RFP
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manager, please provide a client reference including client contact name, title,
address, telephone and fax number. Confirm that your proposal includes the cost of
the interface with the Board’s current pharmacy benefit manager.
182.
You are required to interface with the Plan’s medical management vendor. Confirm
that you can accommodate the current medical management data file layout located
in Appendix T of this RFP. Note any exceptions or concerns you may have with
this file layout. Note any additional data fields you would require to accommodate
this file layout. If you currently interface with a medical management vendor,
please provide a client reference including client contact name, title, address,
telephone and fax number. Confirm that your proposal includes the cost of the
interface with the Board’s current medical management vendor.
183.
You are required to interface with the Plan’s wellness and health promotion vendor.
Confirm that you can accommodate the current wellness and health data layout file
located in Appendix U of this RFP. Note any exceptions or concerns you may have
with this file layout. Note any additional data fields you would require to
accommodate this file layout. If you currently interface with a wellness and health
promotion vendor, please provide a client reference including client contact name,
title, address, telephone and fax number. Confirm that your proposal includes the
cost of the interface with the Board’s current wellness and health vendor.
184.
You are required to interface with the Plan’s provider network administrator.
Confirm that you can accommodate the current provider network data layout file
located in Appendix V of this RFP. Note any exceptions or concerns you may have
with this file layout. Note any additional data fields you would require to
accommodate this file layout. If you currently interface with a provider network
administrator, please provide a client reference including client contact name, title,
address, telephone and fax number. Confirm that your proposal includes the cost of
the interface with the Board’s current provider network administrator.
185.
You are required to interface with the Advanced Health System’s national network.
Confirm that you can accommodate the current data layout file located in Appendix
W of this RFP. Note any exceptions or concerns you may have with this file layout.
Note any additional data fields you would require to accommodate this file layout.
If you currently interface with a national network, please provide a client reference
including client contact name, title, address, telephone and fax number. Confirm
that your proposal includes the cost of the interface with the national network.
186.
You are required to interface with the Statewide Payroll and Human Resource
System (SPAHRS). Confirm that you can accommodate the current SPAHRS data
layout files located in Appendices G, O, P and Q of this RFP. Note any exceptions
or concerns you may have with this file layout. Note any additional data fields you
would require to accommodate this file layout. If you currently interface with a
statewide payroll system, please provide a client reference including client contact
name, title, address, telephone and fax number. Confirm that your proposal
includes the cost of the interface with SPAHRS.
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187.
Please describe fully your backup/restore procedures.
188.
Describe fully your disaster recovery/contingency and business continuity plans.
189.
Is there an existing contractual arrangement for processing at another site in the
event of a disaster at the proposed hardware location?
190.
During the last six (6) months, what has been the number of times and percentage
of time that your system has been "down"? System down time percentage is
measured by the ratio of total planned system availability to the planned availability
when inquiry operators could not access the system to perform their functions.
191.
Describe any off-site storage features and locations to be used for the Plan's data
files, historical files and other information.
192.
Have you implemented a new computer system within the last six months? Do you
anticipate implementing a new computer system within the next 12 months? If so,
please describe the changes.
193.
Is your computer system owned by your firm? If not, who owns the system?
194.
Confirm that you will provide an Automated Voice Response System for providers
as described in the Scope of Services. Please describe your system.
195.
Confirm that your organization will issue 1099s to providers who receive payments
under the Plan.
196.
How does your system issue individual 1099's to individual physicians if claims are
filed by a clinic?
4.13 CLIENT SERVICE:
197.
Confirm that you are willing to assign a dedicated (but not necessarily exclusive)
account manager to participate in activities relative to all aspects of the contract
between the Board and the TPA. How many additional clients does this individual
routinely handle and what is the average size (in covered lives) of the accounts?
198.
Provide job description of the dedicated (but not necessarily exclusive) account
manager. If you have assigned the dedicated account manager, provide a resume.
199.
Confirm that you are willing to assign an exclusive customer service representative
to receive and respond to Board inquiries and complaints.
200.
Provide job description of the exclusive customer service representative. If you
have assigned the exclusive customer service representative, provide a resume.
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201.
Who will be the corporate officer from your organization which will have ultimate
accountability for this account? Provide a brief resume for this individual.
202.
Are you willing to meet with the Board on a quarterly basis to discuss performance,
address administration issues, and review reports?
203.
Please provide a brief description of the level of service support available for:
a.
b.
Technical/legal compliance/policy research/legislative updates
Legal services for disputed claims/litigation/subrogation
4.14 BANKING
204.
Are participant or provider checks written and mailed internally? If you subcontract
this function, provide the following information for the subcontracted vendor:
a.
b.
c.
d.
e.
f.
g.
h.
205.
Full legal name.
Headquarters address.
The name, title, mailing address, telephone number and facsimile number of the
contact person for this proposal.
A description of the services to be provided.
Length of relationship with this subcontractor
Your evaluation of the subcontractor's performance
As of the proposal due date, the number of years of experience in providing
similar service to those which they will be performing under this contract for
other clients.
Indicate whether you currently have a contract with the subcontractor. If so,
provide copies of such agreement(s).
Describe in detail the banking arrangements you propose to use for the Board.
Please address the following issues:
a.
b.
c.
d.
e.
f.
Are all of the costs of the banking arrangement included in the quoted fees?
Are there additional costs for the Board to use their own bank?
Does your banking system utilize drafts cashed or drafts issued as the basis of
fund withdrawal for claims payments?
Do you require an imprest bank balance? At what level? How is this
determined? If required, is this negotiable?
How would the Board be notified of deposit requirements? Outline the timing
and methodology for such notification?
How would an overdraft situation be handled?
4.15 LEGAL AND LIABILITY:
206.
Provide proof of professional and comprehensive general liability insurance
coverage, including stated amounts and limits.
2010 State and School Employees Health Insurance Management Board TPA RFP
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207.
Has your organization ever been involved in a lawsuit involving any area covered
by this RFP? If yes, provide details including dates and outcomes.
208.
During the past five years, has your organization, related entities, principals or
officers ever been a party in any material criminal litigation, whether directly
related to this RFP or not? If so, provide details including dates and outcomes.
209.
Please provide your company’s (and parent organization, if applicable) audited
financial statements including any auditor’s recommendations or opinions for each
of the last two years.
210.
What assistance will be provided if litigation arises as the result of wholly or
partially denied reimbursement based on TPA’s recommendations?
211.
The Board, at its own expense, reserves the right to audit all records maintained by
the TPA and/or its affiliates relative to the TPA’s performance under this contract.
The TPA agrees that upon forty eight (48) hours notice by the Board to the TPA,
the Board shall have the right to perform financial, performance, and other special
audits on such records maintained by the TPA during regular business hours
throughout the contract period. The TPA agrees that confidential information
including, but not limited to, medical and other pertinent information relative to
participants in the Plan, shall not be disclosed to any person or organization for any
purpose without the expressed, written authority from the Board. The selected TPA
will make available all records, as defined by the selected auditor, for review at no
cost to the Board. Any ancillary fees, which may be incurred by the Board for onsite audits, should be included in your proposed rate for TPA services. Please
indicate your acceptance of this proposal requirement and willingness to cooperate.
4.16 IMPLEMENTATION:
212.
Include a copy of your implementation project plan that indicates a service start date
of January 1, 2012. Identify tasks, critical events, time lines and the responsible
parties.
213.
If your organization is selected by the Board as its TPA on April 27, 2011, will you
be fully operational and have all contractual processes and procedures in place by
January 1, 2012?
214.
Would you be willing to assign a dedicated (not necessarily exclusive) team to
assist with the implementation process? How many dedicated (not necessarily
exclusive) service representatives would be assigned for the initial implementation,
as well as ongoing servicing of the Board's program?
215.
Please confirm that you will be able to accept prior approval requests beginning in
December 2011 for services that are to occur after December 31, 2012.
2010 State and School Employees Health Insurance Management Board TPA RFP
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216.
What is the minimum amount of lead time you believe is necessary to implement
the Plan in an efficient and effective manner?
217.
How do you propose to communicate your services to Plan participants, employer
units, and providers should you be selected to administer the Plan? Will you agree
to participate in regional meetings as reasonably necessary? Is this expense
included in your fees?
218.
Describe the most frequent problems you have encountered during previous
transitions for plans of this size. How were these resolved?
219.
Please confirm that your fee proposal includes all costs associated with
implementation services. You must provide a detailed description of any
implementation service charge(s) not specifically included in your fee proposal.
4.17 PERFORMANCE STANDARDS:
220.
The Board requires guarantees of performance. Please review the performance
standards included in Appendix C and confirm your willingness to accept the
performance standards.
221.
Please provide the actual performance results for your organization:
Performance Standard
Claim Turnaround Time
Financial Accuracy
Processing Accuracy
Telephone Answer Time
Telephone Drop Rate
Call Time on Hold
Actual Results as of December 31, 2010
4.18 REFERENCES:
To facilitate verification, please include all requested contact information in your response.
222.
List six (6) current TPA clients (three (3) of which must be governmental clients)
who can serve as references. Include the following:
a.
b.
The largest account under contract as of January 1, 2011
A new account with at least 25,000 covered lives added within the last three
(3) years
For each reference provide a reference name, full address, contact person, title,
phone and fax number, membership size, list of services you provide, and the
duration of the relationship with your organization. If one account matches more
than one of the requirements listed above, provide an additional reference.
2010 State and School Employees Health Insurance Management Board TPA RFP
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223.
In addition, please provide the names of accounts with greater than 50,000 covered
lives that have terminated their relationship with your organization in the past two
years. Include the client name, a contact person, full address, phone and fax
number, membership size, broad list of services you provided, duration of
relationship and reason for termination.
4.19 FINANCIAL:
224.
Confirm you are willing to guarantee the fees listed in Section 5 Financial Exhibit
for the initial four-year life of the contract.
225.
Confirm there are no other costs to the Board other than those listed in Section 5
Financial Exhibit that will be charged for the services described in this RFP or for
any other services proposed by you.
226.
Confirm that your proposal is valid for a period of at least 180 days subsequent to
the date of submission.
2010 State and School Employees Health Insurance Management Board TPA RFP
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5
Financial Exhibit
The Board requires a bundled administration fee for all service support areas (please refer to
the RFP for descriptions of the TPA functions). Additionally, the Board requires fee
guarantees for years 2012, 2013, 2014 and 2015. Consideration will be given to vendors who
provide fee guarantees for year 2016.
Please include your “bundled” TPA fee per employee per month. For the purpose of this exhibit,
Employee is defined as active and COBRA employees, non-Medicare retirees and Medicare
retirees and does not include dependents. The Plan’s current enrollment information is located in
Appendix A of this RFP. Provide financial information for the initial four years of the
contract and the optional fifth year.
Service Category
01/01/1212/31/12
01/01/1312/31/13
01/01/1412/31/14
01/01/1512/31/15
01/01/1612/31/16
"Bundled" TPA
Fee Per Employee
per Month:
_______
_______
_______
_______
_______
Service Category
01/01/1112/31/11
01/01/1212/31/12
01/01/1312/31/13
01/01/1412/31/14
01/01/1512/31/15
Ad-Hoc Reports
_______
_______
_______
_______
_______
Programming for
Benefit, Network, or
Other Plan Changes
_______
_______
_______
_______
_______
__________________
_______
_______
_______
_______
_______
Run-Out Claims
Administration (180 days)
_______
_______
_______
_______
_______
Miscellaneous Services:
Other (Specify):
The Board will not pay any upfront fees prior to the 1/1/12 implementation date for services. All
implementation fees or charges must be included in the administrative services fees quoted herein.
All other fees or charges related to any service to be provided must be identified.
2010 State and School Employees Health Insurance Management Board TPA RFP
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6
Statutory Requirement
You must provide a statement whether or not the provision applies to you. Failure to
provide this disclosure statement will result in your proposal being eliminated from further
consideration.
Section 25-15-9(1)(a) of the Mississippi Code states that "...each person, agent, or corporation
which during the previous fiscal year, has assisted in the development of the Plan or employed or
compensated any person who assisted in the development of the Plan, and which bids on the
administration or servicing of the Plan, shall submit to the board a statement accompanying the bid
explaining in detail its participation with the development of the Plan. This statement shall include
the amount of compensation paid by the bidder to any such employee during the previous fiscal
year. The board shall make all such information available to the members of the advisory council
and those legislators, or their designees, who may attend meetings of the advisory council before
any action is taken by the board on the bids submitted. The failure of any bidder to fully and
accurately comply with this paragraph shall result in the rejection of any bid submitted by that
bidder or the cancellation of any contract executed when the failure is discovered after the
acceptance of that bid." The following list includes persons, agents and corporations who contract
with or assist the board in preparing and developing the Plan:
Actuary: Wm. Lynn Townsend, FSA, MAAA
PricewaterhouseCoopers, LLP
O'Connell Ann - Partner; Yovino Charles - Partner; Cox Edward Patrick - Managing Director;
Weber Donald - Managing Director; Giddings Tracey - Director; Nipp Mary - Director; Pascual
Murray - Director; Posen Kathryn - Director; Rosenberg William - Director; Schaper Jon Director; Schweitzer Laura Gooding - Director; Sica Joanne - Director; Toplin John - Director;
Ashbourne Pamela - Senior Consultant; Chang Michael Yu-Pin - Senior Consultant; Dalmasso
Sean - Senior Consultant; Fears Erin - Senior Consultant; Irwin Richard - Senior Consultant;
Kaminski Elizabeth - Senior Consultant; Lessely Heather - Senior Consultant; Mazoway Jackie Senior Consultant; Miller Stephanie - Senior Consultant; Pascual Murray - Senior Consultant;
Taylor Slate - Senior Consultant; Vitale Wendy - Senior Consultant; Yang Sara - Senior
Consultant; Beers Sherri - Senior Consultant; Cao Lishan - Senior Consultant; Czerwinski Richard
- Senior Consultant; Harmon Jay - Senior Consultant; Harrell Richard - Senior Consultant;
Mitchell Karen - Senior Consultant; Rakes Annamarie - Senior Consultant; Reuter Andrew Senior Consultant; Shih David - Senior Consultant; Thompson Laura - Senior Consultant; Chai
Michael - Consultant; Gao Meihua - Consultant; Ho Nienh - Consultant; Shah Anish - Consultant;
Song Jiesi - Consultant; Kilmer Andrew - Associate; Patel Ankit - Associate; West-Fahey Garrett Associate; Garcia George - Technical; Jayroe Mellony - Technical; Morgan Sondra - Technical;
Douglas Susan - Administrative; Duncan Claudette - Administrative; Ihnen Nancy Administrative; Morgan Sondra - Administrative; Smith Sharon - Administrative; Urey Andra Administrative.
2010 State and School Employees Health Insurance Management Board TPA RFP
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Department of Finance and Administration
Employees who are assisting the Board in preparing and developing the State of Mississippi State
and School Employees’ Life and Health Insurance Plan include: Kevin Upchurch – Executive
Director; Rita Wray – Deputy Executive Director; Office of Insurance Staff: Teresa Planch – State
Insurance Administrator; Richard Self – Deputy Director; Steven May – Director, Accounting and
Analysis; Edie Mills – Director, Benefits and Participant Services; and Cheryl Turner – Director of
Special Programs.
Health Insurance Management Board
Health Insurance Management Board members who are assisting in preparing and developing the
State of Mississippi State and School Employees’ Life and Health Insurance Plan include: Kevin
Upchurch (Chairman) – Executive Director, Department of Finance and Administration; Dr. Tom
Burnham – State Superintendent of Education; Liles Williams – Chairman, Workers’
Compensation Commission; Mike Chaney – Commissioner, Department of Insurance; Dr. Hank
Bounds – Commissioner, Institutions of Higher Learning; Pat Robertson- Executive Director,
Public Employees’ Retirement System; Lynn Fitch - Director, State Personnel Board; Dr. Eric
Clark- Executive Director, State Board of Community and Junior Colleges; Christopher Burkhalter
– Bickerstaff, Whatley, Ryan, & Burkhalter Consulting Actuaries; Larry Fortenberry – President,
Executive Planning Group; The Honorable Alan Nunnelee – Chairman, Senate Appropriations
Committee; The Honorable Johnny Stringer – Chairman, House Appropriations Committee; The
Honorable Walter Robinson, Jr. – Chairman, House Insurance Committee; and The Honorable
Eugene Clarke – Chairman, Senate Insurance Committee.
2010 State and School Employees Health Insurance Management Board TPA RFP
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7
Statement of Compliance and Draft Contract
This section contains a Statement of Compliance and draft contract. Please review this section
carefully and include a signed Statement of Compliance with your completed proposal. If you
object to any of the contract conditions, any requirements as set forth in Section 3 Scope of
Services in this RFP, or any requirements listed in this RFP, please note and explain your objection
in detail on the Statement of Compliance. Proposer must submit a signed Statement of
Compliance.
2010 State and School Employees Health Insurance Management Board TPA RFP
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Statement of Compliance
We have agreed to adhere to all conditions and requirements as set forth in the State of Mississippi
Request For Proposal for TPA Services including the draft contract contained in Section 8, except
as listed below:
Name
Signature
Title
Date
Company
Please have the appropriate officer sign this statement and include it as part of your proposal
2010 State and School Employees Health Insurance Management Board TPA RFP
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8
Draft Third Party Medical Claims Administration Services Contract
This Third Party Medical Claims Administration Services Contract (Contract) is made by and
between the State of Mississippi State and School Employees’ Health Insurance Management Board
(Board), acting administratively through the Department of Finance and Administration (DFA), and
______________ the (TPA) on January 1, 2012. Under the following terms and conditions the TPA
agrees to render services as herein described to the participants of the Mississippi State and School
Employees’ Life and Health Insurance Plan (Plan) beginning January 1, 2012.
1.
2.
IDENTITY OF AND RELATIONSHIP BETWEEN THE PARTIES
a.
The TPA, a corporation organized under the laws of the state of _______, is a TPA
organized for the purpose of providing Third Party Medical Claims Administration
Services as herein described.
b.
The State and School Employees Health Insurance Management Board (Board)
acting administratively through the Department of Finance and Administration
(DFA), an agency of the State, administers the Plan. DFA acts on behalf of the Board
in executing the Board’s day to day operational responsibilities concerning the Plan’s
administration.
c.
The TPA and the Board are independent legal entities. Nothing in this Contract shall
be construed to create the relationship of employer and employee or principal and
agent or any relationship other than that of independent parties contracting with each
other solely for the purpose of carrying out the terms of this Contract.
d.
Neither the TPA, the Board, nor any of their respective agents or employees shall
control or have any right to control the activities of the other party in carrying out the
terms of this Contract, nor shall either party, its respective agents or employees, be
liable to third parties for any act or omission of the other party.
e.
Nothing in this Contract is intended to be construed, nor shall it be deemed to create,
any right or remedy in any third party.
DEFINITIONS
a.
"Allowable Charge" means the lesser of the submitted charge or the amount
established by the Plan, as provided through provider network contract(s) with a
Participating Provider or based on analysis of provider charges for non-Participating
Providers, as the maximum amount for all such provider services covered under the
terms of the Plan.
b.
“Complete Claim” means necessary information required by the TPA to adjudicate
the claim.
c.
"Health Care Services" means Hospital Services, Medical Services, and/or other
covered services or supplies for which payment may be sought under the terms of the
Plan.
2010 State and School Employees Health Insurance Management Board TPA RFP
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3.
d.
“Health Benefit Plan” or “Plan” means the self-insured Mississippi State and School
Employees’ Life and Health Insurance Plan as defined in §Section 25-15-1 et. seq.
e.
“Health Insurance Portability and Accountability Act (HIPAA)” shall refer to the
Health Insurance Portability and Accountability Act of 1996.
f.
“Hospital Services" means acute care inpatient and hospital outpatient services or
supplies for which payment may be sought under the terms of the Plan. "Hospital
Services" does not include long-term, non-acute care inpatient services.
g.
"Third Party Medical Claims Administrator" means the organization under contract to
the Board responsible for processing claims for the Plan.
h.
"Medical Services" means patient care services or supplies for which payment may be
sought under the terms of the Plan, other than Hospital Services.
i.
“Network” means the organization(s) under contract with the Board responsible for
direct contracting services for the development of a provider network(s) or the
organization(s) under contract with the Board responsible for providing an established
provider network(s).
j.
“Out of Network Review” means the process of determining if the Plan will allow innetwork level benefits for services provided by a non-participating Network Provider
or in a non- participating Network facility
k.
“Plan” means the self-insured Mississippi State and School Employees’ Life and
Health Insurance Plan as defined in §Section 25-15-1 et. seq.
l.
"Plan Document" (PD) is the document that states the benefits and eligibility terms of
the Plan. This document is published and maintained by the Board.
m.
“Plan Participant" means an individual who is eligible to receive Health Care
Services for which payment may be sought under the terms of the Health Benefit
Plan.
n.
“Provider” means a physician or other medical practitioner, health care professional,
and facility as defined in the Plan Document.
RESPONSIBILITIES OF THE TPA
a.
The TPA shall have a dedicated (but not necessarily exclusive) account manager to
participate in activities relative to all aspects of the Contract between the Board and
the TPA and to meet with the Board as requested to review Plan utilization, and
attend the Board’s monthly meetings and make recommendations regarding services
and/or programs.
2010 State and School Employees Health Insurance Management Board TPA RFP
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b.
The TPA shall provide all services directly related to this Contract from an office
located within the continental United States.
c.
The TPA shall be solely responsible for all applicable taxes, insurance, licensing, and
other costs of doing business. Should TPA default in these or other responsibilities,
jeopardizing TPA’s ability to perform services effectively, this Contract may be
terminated for default at the Board’s sole discretion.
d.
The TPA shall hire and maintain sufficient staff to meet the needs of the Board and
the Plan Participants.
e.
The TPA, at its own cost, agrees to participate in approximately fifty (50) benefit fairs
per year to educate Plan Participants.
f.
The TPA agrees to participate in activities with the Board in responding to Plan
participant or provider inquiries or complaints relating to TPA services.
g.
The TPA shall cooperate with the Board and with all other contractors of the Board
with respect to ongoing coordination and delivery of Health Care Services and in any
transition of responsibilities.
h.
The TPA shall provide other services for which the TPA has the technical capability
to render.
i.
The TPA agrees to provide whatever information is deemed necessary by the Board,
the Board’s consultants and/or other Board vendors and has (or is able to establish)
data interface with the Board’s vendors for the transmittal/receipt of required data
elements.
j.
The TPA shall be in compliance with all applicable requirements of HIPAA including
the Administrative Simplification and Security Rule provisions.
k.
The TPA, at its own cost, shall supply all forms and materials necessary and required
to install and administer the services provided by the TPA. Loading eligibility data
and establishing data transfer and system interface according to the specifications in
the Request for Proposals will not result in any additional fees to the Board. In the
event the Board contracts with vendors different from those under contract with the
Board effective January 1, 2012, and the TPA’s file specification is not used, any
programming or software development required by the TPA to interface with the
vendors will be billed to the Board at the rate referenced in Exhibit ___, “Third Party
Medical Claims Administration Services Administrative Fees” of this Contract.
l.
The TPA, at its own cost, shall provide the TPA's informational materials to all Plan
participants enrolled in the Plan at the time of implementation including the cost of
mailing any communication materials to participant home locations. The TPA, at its
own cost, shall provide and maintain a supply of the TPA's informational materials to
the Board. The TPA, at its own cost, shall provide a supply of the TPA's
informational materials to all departments, agencies, universities, community/junior
2010 State and School Employees Health Insurance Management Board TPA RFP
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colleges, public school districts, and public libraries at the time of implementation
and throughout the terms of the Contract when requested by a department, agency,
university, community/junior college, public school district, or public library. Plan
participants enrolled after the implementation will receive informational materials
from the Plan participant’s employing department, agency, university,
community/junior college, public school district, or public library.
m.
The TPA shall furnish standard reports in a form and content approved by the Board
and illustrated in Exhibit ___, “Third Party Medical Claims Administration Services
Vendor Reports” of this Contract. These reports shall be provided, at the Board's
request, in a hard copy and/or electronic media format. Additionally, the TPA shall
provide custom reports at the Board's request. The TPA shall provide the Board, for
the Board's approval, the time and cost for the development of custom reports prior to
the development of the report. The cost of custom reports shall be based upon the
number of hours required for programming at the hourly programming cost indicated
in Exhibit ____, “Third Party Medical Claims Administration Services
Administrative Fees” of this Contract.
n.
The TPA shall provide optional services as agreed to in writing by the Board and
TPA and included as an exhibit to this Contract.
o.
The TPA is required to notify and receive approval from the Board prior to (i) using
the Board's or the Plan name or Plan benefit information in any publications or
printed material or (ii) any publications or printed material mailed or provided
directly to Plan participants or (iii) any change in the core services to be provided by
the TPA pursuant to this Contract. Breach of any one of these may be reason and
cause for immediate cancellation of this Contract, at the discretion of the Board.
p.
The TPA shall be responsible for responding to inquiries from Plan participants,
providers, and the Board regarding the services provided by the TPA under this
Contract through a toll-free telephone line. The normal service hours, in Central
Time, are 7:00 a.m. to 6:00 p.m. Monday through Friday each week of the year
excluding TPA holiday schedules, closure due to force majeure or closure due to
causes beyond the reasonable control of the TPA. In addition, voice mail service
shall be available 24-hours, 7 days-a-week, other than scheduled maintenance times,
to Plan participants and providers.
q.
The TPA, at its own cost, shall provide routine distribution of ID cards, including
printing, mailing, and postage. The TPA, at its own cost, shall provide ID cards
directly to the Plan Participant’s home address for (1) the initial enrollment of the
Plan, (2) future new hires, (3) Plan participants who change coverage category (e.g.
single to family) and (4) replacement of lost cards. Plan participants with single
coverage should receive one (1) ID card; Plan participants with dependent coverage
should receive two (2) ID cards. The information to be printed on each ID card will
include, at a minimum, the Plan Participant’s name and identification number, Plan
name, the TPA name and toll free customer service line number, in the Board’s
specifications.
2010 State and School Employees Health Insurance Management Board TPA RFP
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r.
The TPA, at its own cost, shall conduct one (1) customer satisfaction survey within
the initial third quarter of the Contract period and one (1) annually thereafter. The
contents of the satisfaction survey must be agreed upon by the Board and the TPA.
s.
The TPA is required to notify and receive approval from the Board prior to any
change in the core services to be provided by the TPA pursuant to this Contract.
Failure of the TPA to receive approval from the Board prior to any change in the core
services pursuant to this Contract may be considered breach of contract and reason
and cause for immediate cancellation of this Contract.
t.
The TPA is required to notify and receive approval from the Board prior to using the
Board’s or the Plan’s name, or Plan benefit information in any publications or printed
material or mailing or distributing materials to Plan participants. Breach of any one of
these is reason and cause for immediate cancellation of this Contract.
u.
At least one member of the TPA’s account management staff assigned to the Board
shall be available to the Board, Monday through Friday, each week of the year
between the hours of 8:00 a.m. and 5:00 p.m. Central Time, excluding holiday
schedules as agreed upon by the TPA and the Board.
v.
The TPA agrees the Plan’s eligibility information is the property of the Board and
prior approval of the Board must be received for any utilization of this information.
w.
The TPA, as of the effective date of the services to be provided under this Contract
and continuing for the duration of this Contract, shall process all claims that are
provided before the termination date of this Contract. Upon termination of this
Contract, the TPA shall process all claims that are provided before the termination
date of this Contract and are received by the TPA within 180 days after the
termination date of this Contract.
x.
The TPA’s claims processing services shall include, at a minimum but is not limited
to, the following;
1. verification of eligibility of the employee and dependent participants based on the
Board provided enrollment and termination information on Plan participants;
2. review of claims submitted to determine the coverage in accordance with the
Plan’s parameters
3. receipt, processing, adjustment, and authorization of claim payments for the Plan
in accordance with the terms of the Plan;
4. provision of claim forms;
5. provision of explanation of benefit (EOB) forms to Plan participants with respect
to all claims and maintenance of the following information with respect to all
claims: Employee name, Employee identification number, patient name or other
specific identifier, claim number, provider number, provider name, service date,
type of service, amount of charges, co-payment/co-insurance amount, deductible
amount, amount allowed to the claimant, and reason codes that specify the reason
for claim payment or denial;
6. provision of 1099 forms for providers, to the extent required by Federal law;
2010 State and School Employees Health Insurance Management Board TPA RFP
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7.
8.
9.
assignment of adequate staff to perform timely and accurate claims processing
and customer service, including staff to answer phone inquiries and
correspondence regarding benefits, claim status and verification of eligibility,
appeals and the timely communication of the outcome, and those other functions
deemed necessary as mutually agreed by the parties;
apply quality control processes to regularly evaluate the performance and
accuracy of the claims processing systems and the claims processing staff, and at
the request of the Board, but at least annually, make resulting findings of such
evaluation available to the Board;
upon a change in Federal Law that would require the filing of reports with the
Federal Government by the Board in connection with this Contract, the TPA and
the Board will discuss and negotiate the preparation of such reports for the
approval and signature of the Board.
y.
The TPA shall provide initial claims review upon the request of a Plan Participant
with respect to claims partially or fully denied for payment by the TPA. The TPA
agrees that a participant may request a review of any partially or fully denied claim to
the TPA. The TPA agrees that if after the claim has been reviewed and benefits are
again partially or fully denied, the Plan Participant will be informed of such decision
in accordance with the federal Patient Protection and Affordable Care Act of 2010
(PPACA). In any individual case, the TPA agrees that the Board has the right to
direct the TPA to pay or provide benefits.
z.
The TPA shall maintain contracts with a minimum or three (3) independent review
organizations (IRO) that are accredited by URAC or by a similar nationallyrecognized accrediting organization to conduct external reviews as required by
PPACA.
aa.
The TPA shall provide coordination of benefits services. The TPA shall maintain
information regarding a Plan Participant’s COB status. The TPA shall reject primary
payment for Plan participants for whom the Plan is secondary and shall provide for
secondary payment of claims, either electronically or by submission of a hard copy
claim form to be obtained from the TPA.
bb.
The TPA shall be responsible for addressing and correcting, in a timely manner, any
errors detected during any audit. Any claim processing error will be adjusted to the
proper account.
cc.
The TPA shall provide access to its claims processing system to Board staff. Access
by the Board’s staff must include, at a minimum, review of Plan Participant claims
history and eligibility.
dd.
The TPA shall provide web-based reporting tools that allow the Board to view, print,
and download reports to spreadsheet software.
ee.
The TPA shall provide services listed in Exhibit ___, “Third Party Medical Claims
Administration Services” of this Contract.
2010 State and School Employees Health Insurance Management Board TPA RFP
Page 67
ff.
4.
5.
The Claims Administrator, upon termination of this Contract shall adjudicate and
process all claims for Health Care Services with service dates prior to the termination
date of this Contract that are received by the Claims Administrator within 180 days
after the termination date of this Contract.
RESPONSIBILITIES OF THE BOARD, ADMINISTRATOR OF THE PLAN
a.
The Board reserves the exclusive right to amend, reduce, or eliminate any part of the
Plan or change any benefits at any time. To the extent that such amendment,
reduction, elimination, or change materially affects the services provided by the TPA
under this Contract, the Board shall notify the TPA of such change via a letter of
authorization in a timely manner and in advance of such change. In case of conflict
between this Contract and the Plan Document, the Plan Document will prevail.
b.
The Board or its designee shall provide educational material to all Plan participants
explaining conditions of coverage, cost sharing, benefit design, and financial
incentives encouraging compliance with the Plan.
c.
The Board shall have final authority on any appeal, application, and interpretation of
the Plan’s benefits or eligibility policies. Benefit determination shall not affect the
attending physician’s responsibility to provide all medically necessary care to covered
individuals.
d.
The Board will not disseminate, sell, or license any proprietary information belonging
to the TPA to others without the TPA’s prior written approval, unless the information
is subject to the Public Records Law of the State or is required to be released by law.
CONSIDERATION
a.
The Board shall not provide any prepayments or initial deposits in advance of
services being rendered. Only those services agreed to by Contract shall be
considered for reimbursement/compensation by the Board. Payment for any and all
services provided by the TPA to the Board and/or the Plan shall be made only after
said services have been duly performed and properly invoiced.
b.
In consideration for the services provided by the TPA under this Contract, the Board
shall compensate the TPA through administrative fees illustrated in Exhibit _____,
“Third Party Medical Claims Administration Services Administrative Fees” of this
Contract. In accordance with State law and applicable contract conditions, the Board
will compensate the TPA such fees after the appropriate services have been rendered.
The TPA must submit all invoices, in a form acceptable to the Board with all the
necessary supporting documentation, prior to any payment to the TPA of any
administrative fees. Administrative fees must be invoiced on a monthly basis, in
sufficient detail and format as determined by the Board. Such invoices shall include,
at a minimum, a description of the service(s) provided, the quantity or number of
units billed, the compensation rate, the time period in which services were provided,
total compensation requested for each individual service being billed, and total
administrative fees requested for the period being invoiced. The Board agrees to
make payment to the TPA on any undisputed amounts within thirty (30) days from
2010 State and School Employees Health Insurance Management Board TPA RFP
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the date services were rendered or the date of receipt of the invoice, whichever comes
last. Upon the effective date of termination of this Contract, the TPA’s obligation to
provide any further services under this Contract shall cease. The TPA shall, however,
remain liable for any obligations arising hereunder prior to the effective date of such
termination.
6.
c.
The payment of an invoice by the Board shall not prejudice the Board's right to object
or question any invoice or matter in relation thereto. Such payment by the Board
shall neither be construed as acceptance of any part of the work or service provided
nor as an approval of any costs invoiced therein. The TPA's invoice or payment may
be subject to further reduction for amounts included in any invoice or payment
theretofore made which are determined by the Board, on the basis of audits, not to
constitute allowable costs. Any payment shall be reduced for overpayment or
increased for underpayment on subsequent invoices. For any amounts which are or
shall become due and payable to the Board and/or the Plan by the TPA, the Board
reserves the right to (1) deduct from amounts which are or shall become due and
payable to the TPA under Contract between the parties; or (2) request and receive
payment directly from the TPA within fifteen (15) days such request, at the Board’s
sole discretion.
d.
The TPA agrees to the performance standards and liquidated damages relative to such
services as outlined in Exhibit ____, “Performance Standards and Liquidated
Damages” of this Contract.
e.
The Board agrees to make payment in accordance with Mississippi law on “Timely
Payments for Purchases by Public Bodies”, Section 31-7-301, et seq. of the 1972
Mississippi Code Annotated, as amended, which generally provides for payment of
undisputed amounts within forty-five (45) days of receipt of the invoice. Payments
by state agencies using the Statewide Automated Accounting System (SAAS) shall be
made and remittance information provided electronically as directed by the State.
These payments shall be deposited into the bank account of the TPA’s choice. TPA
understands and agrees that the State is exempt from the payment of taxes. All
payments shall be in United States currency. No payment, including final payment,
shall be construed as acceptance of defective or incomplete work, and the TPA shall
remain responsible and liable for full performance.
f.
The Board requires the TPA to submit invoices and supporting documentation
electronically throughout the term of the Contract. Invoices shall be submitted to the
Board using the processes and procedures identified by the Board. The TPA shall
submit all invoices, with all of the necessary supporting documentation, prior to any
payment of allowable costs.
AVAILABILITY OF FUNDS
It is expressly understood and agreed that the obligation of the Board to proceed under this
Contract is conditioned upon the appropriation of funds by the Mississippi State Legislature
and the receipt of State and/or federal funds. If the funds anticipated for the continuing
fulfillment of this Contract are, at anytime, not forthcoming or insufficient, either through the
2010 State and School Employees Health Insurance Management Board TPA RFP
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failure of the federal government to provide funds or of the State of Mississippi to
appropriate funds, or the discontinuance or material alteration of the program under which
such funds were provided, or if funds are not otherwise available to the State, the Board shall
have the right upon ten (10) working days written notice to the TPA, to terminate this
Contract without damage, penalty, cost, or expenses to the Board of any kind whatsoever.
The effective date of termination shall be as specified in the notice of termination.
7.
ACCESS TO RECORDS
a.
The TPA agrees that data contained on tapes, discs, files, batch files, and other
records pertinent to the Health Care Services received by Plan participants, unless not
otherwise prohibited by law, are the property of the Board and must be made capable
of separate retrieval and distribution and shall be made readily available to the Board
upon request. The TPA’s physical security of all such records shall comply with or
exceed all applicable state and federal legal requirements. The Board may from time
to time request and the TPA shall provide a copy of to such procedures to the Board,
such requests from the Board will not be made on an unreasonable basis.
b.
The TPA shall prepare and maintain appropriate records concerning services rendered
under this Contract by the TPA, including any such records required by law, for a
period of at least seven (7) years, unless law or regulation requires longer periods.
c.
All medical, financial, and personal information reviewed and collected in connection
with this Contract regarding individual Plan participants shall be held in strict
confidence in compliance with all applicable state and federal legal requirements,
specifically the provisions of the Health Insurance Portability and Accountability Act
(HIPAA) and shall not be released, disclosed, published, or used for any purpose not
defined in this Contract by the TPA without the written consent of the Board, except
to the Board or its TPA. Nothing contained herein shall preclude Plan participants
from obtaining their individual medical records.
d.
Except as may otherwise be required by law, the TPA may not release any
information or reports relative to the Plan without prior written authorization by the
Board.
e.
The TPA agrees that the Board or any of its duly authorized representatives, at any
time during the term of this Contract, shall have access to and the right to audit and
examine any pertinent books, documents, papers, and records of the TPA related to
the TPA’s charges and performance under this Contract. Such records shall be kept
by the TPA for a period of seven (7) years after final payment under this Contract,
unless the Board authorizes in writing, their earlier disposition. The TPA agrees to
refund to the Board any overpayment disclosed by any such audit. However, if any
litigation, claim, negotiation, audit, or other action involving the records has been
started before the expiration of the seven (7) year period, the records shall be retained
until completion of the action and resolution of all issues which arise from it. The
Board shall also maintain the right to perform financial, performance, and other
special audits on such records maintained by the TPA during regular business hours
throughout the Contract period. The TPA shall make available for review all records
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as defined by the selected auditor at no cost to the Board. The TPA agrees that
confidential information including, but not limited to, medical and other pertinent
information relative to Plan participants in the Plan, shall not be disclosed to any
person or organization for any purpose without the expressed, written authority from
the Board or as otherwise required by law.
8.
9.
f.
Information generated by the TPA may be subject to the Public Records Law of the
State. Unless otherwise required by law or Court order, the Board shall not utilize,
disseminate, sell, or license any proprietary information belonging to the TPA to
others without the TPA’s prior written approval.
g.
The TPA recognizes that it may have access to certain confidential and proprietary
information pertaining to the business of the Board, including but not limited to,
policy benefits, names and addresses of Plan participants, employer units and
contracts with other parties. The TPA agrees that it will not, at any time, directly or
indirectly, disclose such confidential or proprietary information to any other person or
organization for any purpose, except as may be required by law, authorized by the
individual to which such information pertains, or as reasonably relates to the services
being provided by the TPA and contemplated by the terms of the Contract, without
the express, written approval of the Board.
STANDARD OF CARE/REMEDIES
a.
Standard of Care. The TPA shall exercise reasonable care and due diligence
consistent with standards in the industry in the performance of its obligations under
this Contract.
b.
Remedies. Each party shall have available to it all remedies available at law or
equity.
CONTRACT TERM
a.
The effective date of this Contract will be January 1, 2012. The Contract’s term will
be for four (4) years with an option to renew for one (1) year at the Board’s
discretion. By September 1, 2014, the Board will notify the TPA, in writing, of the
Board’s intent as to renewal of the Contract for one additional year. The effective
date of the services administered by the TPA shall be January 1, 2012. The TPA shall
fully implement the program by January 1, 2012.
b.
This Contract may be terminated by either party, with or without cause, upon at least
one hundred twenty (120) days prior written notice of intent to terminate provided to
the other party.
c.
All records and information provided by the Board or through its third party
contractors to the TPA are the sole property of the Board and shall be returned to the
Board within thirty (30) days of the termination date of this Contract. The TPA shall
be entitled to retain and utilize data that have been captured, computed, or stored in
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the TPA’s databases to the extent that such data cannot be identified or linked to the
Board, Plan, or an individual Plan participant.
d.
10.
Upon termination of this Contract, the TPA shall fully cooperate with the Board and
the new TPA during the transition of the Plan business to the new TPA. Upon request
of the Board, the TPA shall provide all information maintained by the TPA in relation
to the Plan in a time frame specified by the Board. Information provided shall be in a
format designated by the Board. The TPA shall provide such explanation of the
information provided as to facilitate a smooth transition. Explanations of the
information shall include, but not be limited to, file layouts, data dictionary, and
legends.
APPLICABLE LAW/VENUE
This Contract shall be governed by and construed in accordance with the laws of the State of
Mississippi, excluding its conflicts of laws provisions. The TPA shall comply with
applicable federal, state, and local laws and regulations. Venue for any action shall be in the
First Judicial District, Hinds County, Mississippi.
11.
ASSIGNMENT/SUBCONTRACTING
The TPA shall not assign or subcontract, in whole or in part, its rights or obligations under
this Contract to any other organization without prior written consent of the Board. Any
attempted assignment without said consent shall be void and of no effect.
12.
COMPLIANCE WITH LAWS
The TPA understands that the State of Mississippi is an equal opportunity employer and
therefore maintains a policy which prohibits unlawful discrimination based on race, color,
creed, sex, age, national origin, physical handicap, disability, or any other consideration
made unlawful by federal, State, or local laws. All such discrimination is unlawful and the
TPA agrees during the term of this Contract that the TPA will strictly adhere to this policy in
its employment practices and provision of services. The TPA shall comply with, and all
activities under this Contract shall be subject to all applicable federal, State of Mississippi,
and local laws and regulations, as now existing and as may be amended or modified.
13.
EMPLOYEE STATUS VERIFICATION
The TPA represents and warrants that it will ensure its compliance with the Mississippi
Employment Protection Act, codified as Section 71-11-1 et seq., of the Mississippi Code
Annotated (1972, as amended), and will register and participate in the status verification
system for all newly hired employees. The term “employee” as used herein means any person
that is hired to perform work within the State of Mississippi. As used herein, “status
verification system” means the Illegal Immigration Reform and Immigration Responsibility
Act of 1996 that is operated by the United States Department of Homeland Security, also
known as the E-Verify Program, or any other successor electronic verification system
replacing the E-Verify Program. The TPA agrees to maintain records of such compliance
and, upon request of the State, to provide a copy of each such verification to the State. The
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TPA further represents and warrants that any person assigned to perform services hereunder
meets the employment eligibility requirements of all immigration laws of the State of
Mississippi. The TPA understands and agrees that any breach of these warranties may
subject the TPA to the following: (a) termination of this Contract and ineligibility for any
state or public contract in Mississippi for up to three (3) years, with notice of such
cancellation/termination being made public, or (b) the loss of any license, permit,
certification or other document granted to the TPA by an agency, department or
governmental entity for the right to do business in Mississippi for up to one (1) year, or (c)
both. In the event of such termination/cancellation, the TPA would also be liable for any
additional costs incurred by the State due to contract cancellation or loss of license or permit.
14.
INDEPENDENT CONTRACTOR
The TPA shall perform all services as an independent TPA and shall at no time act as an
agent for the State. No act performed or representation made, whether oral or written, by the
TPA with respect to third parties shall be binding upon the Board.
15.
MODIFICATIONS/AMENDMENTS/ RENEGOTIATION
This Contract may not be modified or amended, in whole or in part, except by written
amendment signed by the parties hereto. This Contract may be modified, altered or changed
only by written agreement signed by the TPA and the Board. The parties agree to renegotiate
this Contract if federal and/or State revisions of any applicable laws or regulations make
significant changes in this Contract necessary.
16.
PROCUREMENT REGULATIONS
This Contract shall be governed by the applicable provisions of the Mississippi Personal
Service Contract Review Board Regulations, a copy of which is available from the
Mississippi State Personnel Board located in the Robert G. Clark Jr. Building at 301 North
Lamar Street, Suite 100, Jackson, Mississippi 39201 or by accessing their website at
www.spb.state.ms.us.
17.
REPRESENTATION REGARDING CONTINGENT FEES
The TPA represents that it has not retained a person to solicit or secure a State contract upon
an agreement or understanding for a commission, percentage, brokerage, or contingent fee.
The Board will not pay any commissions and/or any brokerage, percentage, finder’s, service,
or contingent fees for securing or executing any of the services outlined in this Contract.
18.
REPRESENTATION REGARDING GRATUITIES
The TPA represents that it has not violated, is not violating, and agrees that it will not violate
any prohibition against gratuities set forth in Section 7-204 (Gratuities) of the Mississippi
Personal Service Contract Procurement Regulations.
2010 State and School Employees Health Insurance Management Board TPA RFP
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19.
20.
TERMINATION FOR CONVENIENCE
a.
Termination. The Board may, when the interests of the State so require and, upon at
least ninety (90) days prior written notice, terminate this Contract in whole or in part
for the convenience of the State. The Board shall give written notification of the
termination to the Vendor specifying the part of the Contract terminated and when
termination becomes effective.
b.
TPA’s Obligations. The TPA shall incur no further obligations in connection with the
terminated work, and on the date set in the notice of termination the TPA will stop
work to the extent specified. The TPA shall also terminate outstanding orders and
subcontracts as they relate to the terminated work. The TPA shall settle the liabilities
and claims arising out of the termination of subcontractors and orders connected with
the terminated work. The Board may direct the TPA to assign the TPA’s right, title,
and interest under terminated orders or subcontracts to the State. The TPA must still
complete the work not terminated by the notice of termination and may incur
obligations as are necessary to do so.
TERMINATION FOR DEFAULT
a.
Default. If the TPA refuses or fails to perform any of the provisions of this Contract
with such diligence as will ensure its completion within the time specified within this
Contract, or any extension thereof otherwise fails to timely satisfy the Contract
provisions or commits any other substantial breach of contract, the Board may notify
the TPA in writing of the delay or nonperformance and if not cured in ten (10) days
or any longer time specified in writing by the Board, the Board may terminate the
TPA’s right to proceed with this Contract or such part of this Contract as to which
there has been delay or failure to properly perform. In the event of termination in
whole or in part, the Board may procure similar supplies or services in a manner and
upon the terms deemed appropriate by the Board. The TPA shall continue
performance of the Contract to the extent it is not terminated and shall be liable for
excess costs incurred in procuring similar goods or services.
b.
TPA’s Duties. Notwithstanding termination of this Contract and subject to any
directions from the Board, the TPA shall take timely, reasonable, and necessary
action to protect and preserve property in the possession of the TPA in which the
State has an interest.
c.
Compensation. Payment for completed services delivered and accepted by the State
shall be at the Contract price. The Board may withhold from amounts due the TPA
such sums as the Board deems to be necessary to protect the Board against loss
because of outstanding lien holders and to reimburse the State for the excess costs
incurred in procuring similar goods and services.
d.
Excuse for Nonperformance or Delayed Performance. Except with respect to defaults
of subcontractors, the TPA shall not be in default by reason of any failure in
performance of this Contract in accordance with its terms (including any failure by
the TPA to make progress in the prosecution of the work here under which endangers
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performance) if the TPA has notified the Board within 15 days after the cause of the
delay and the failure arises out of causes such as: acts of God; acts of the public
enemy; acts of the State and any other governmental entity in its sovereign or
contractual capacity; fires; floods; epidemics; quarantine restrictions; strikes or other
labor disputes; freight embargoes; or unusually severe weather. If the failure to
perform is caused by the failure of a subcontractor to perform or make progress, and
if such failure arises out of causes similar to those set forth above, the TPA shall not
be deemed to be in default, unless the services to be furnished by the subcontractor
were reasonably obtained from other sources in sufficient time to permit the TPA to
meet the Contract requirements. Upon request of the TPA, the Board shall ascertain
the facts and extent of such failure, and, if such Board determines that any failure to
perform was occasioned by any one or more of the excusable clauses, and that, except
for the excusable cause, the TPA’s progress and performance would have met the
terms of the Contract, the delivery schedule shall be revised accordingly, subject to
the rights of the State under the clause of this Contract entitled “Termination for
Convenience”.
21.
e.
Erroneous Termination for Default. If, after notice of termination of the TPA’s right
to proceed under the provisions of this clause, it is determined for any reason that the
Contract was not in default under the provisions of this clause, or that the delay was
excusable under the provisions of this clause, or that the delay was excusable under
the provisions of Paragraph (d) of this clause, the rights and obligations of the parties
shall be the same as if the notice of termination had been issued pursuant to the clause
of this Contract entitled “Termination for Convenience”.
f.
Additional Rights and Remedies. The rights and remedies provided under this clause
are in addition to any other rights and remedies provided by law or under this
Contract.
STOP WORK ORDER
a.
Order to Stop Work. The Board may by written order to the TPA, at any time and
without notice to any surety, require the TPA to stop all or any part of the work called
for by this Contract. This order shall be for a specified period not exceeding ninety
(90) days after the order is delivered to the TPA, unless the parties agree to any
further period. Any such order shall be identified specifically as a stop work order
issued pursuant to this clause. Upon receipt of such an order, the TPA shall forthwith
comply with its terms and take all reasonable steps to minimize the occurrence of
costs allocable to work covered by the order during the period of work stoppage.
Before the stop work order expires, or within any further period to which the parties
shall have agreed, the Board shall either:
i. cancel the stop work order; or
ii. terminate the work covered by such order as provided in the “Termination for
Default” clause or the “Termination for Convenience” clause of this Contract.
b.
Cancellation or Expiration of the Order. If a stop work order issued under this clause
is canceled at any time during the period specified in the order, or if the period of the
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order or any extension thereof expires, the TPA shall have the right to resume work.
An appropriate adjustment shall be made in the delivery schedule or the TPA price, or
both, and the Contract shall be modified in writing accordingly, if:
i. the stop work order results in an increase in the time required for, or in the
TPA’s cost properly allocable to, the performance of any part of this Contract;
and
ii. the TPA asserts a claim for such an adjustment within thirty (30) days after
the end of the period of work stoppage; provided that, if the Board decides
that the facts justify such action, any such claim asserted may be received and
acted upon at any time prior to final payment under this Contract.
22.
c.
Termination of Stopped Work. If a stop work order is not canceled and the work
covered by such order is terminated for default or convenience, the reasonable costs
resulting from the stop work order shall be allowed by adjustment or otherwise.
d.
Adjustment of Price. Any adjustment in Contract price made pursuant to this clause
shall be determined in accordance with the “Modifications / Amendments /
Renegotiation” clause of this Contract.
PRICE ADJUSTMENT
a.
Price Adjustment Methods. Any adjustment in contract price pursuant to a clause in
this contract shall be made in one or more of the following ways:
i. by agreement on a fixed price adjustment before commencement of the
additional performance;
ii. by unit prices specified in the contract; or
iii. by the costs attributable to the event or situation covered by the clause, plus
appropriate profit or fee, all as specified in the contract.
b.
23.
Submission of Cost or Pricing Data. The TPA shall provide cost or pricing data for
any price adjustments subject to the provisions of Section 3-403 (Cost or Pricing
Data) of the Mississippi Personal Service Contract Procurement Regulations.
ORAL STATEMENTS
No oral statement of any person shall modify or otherwise affect the terms, conditions, or
specifications stated in this Contract. All modifications to this Contract must be made in
writing by the Board and the TPA.
24.
OWNERSHIP OF DOCUMENTS AND WORK PAPERS
The Board shall own all documents, files, reports, work papers, and working documentation,
electronic or otherwise, created in connection with the project which is the subject of this
Contract, except for the TPA’s internal administrative and quality assurance files and internal
project correspondence. The TPA shall deliver such documents and work papers to the
Board upon termination or completion of this Contract. The foregoing notwithstanding, the
TPA shall be entitled to retain a set of such work papers for its files. The TPA shall be
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entitled to use such work papers only after receiving written permission from the Board and
subject to any copyright protections.
25.
INDEMNIFICATION
To the fullest extent allowed by law, the TPA shall indemnify, defend, save and hold
harmless, protect, and exonerate the State of Mississippi, its Commissioners, Board
Members, officers, employees, agents, and representatives from and against all claims,
demands, liabilities, suits, actions, damages, losses, and costs of every kind and nature
whatsoever, including, without limitation, court costs, investigative fees and expenses, and
attorneys’ fees, arising out of or caused by the TPA and/or its partners, principals, agents,
employees, and/or subcontractors in the performance of or failure to perform this Contract.
In the State’s sole discretion, the TPA may be allowed to control the defense of any such
claim, suit, etc. In the event the TPA defends said claim, suit, etc., the TPA shall use legal
counsel acceptable to the State; the TPA shall be solely liable for all reasonable costs and/or
expenses associated with such defense and the State shall be entitled to participate in said
defense. The TPA shall not settle any claim, suit, etc., without the State’s concurrence,
which the State shall not unreasonably withhold.
26.
THIRD PARTY ACTION NOTIFICATION
The TPA shall give the Board prompt notice in writing of any action or suit filed and prompt
notice of any claim made against the TPA by any entity that may result in litigation related in
any way to this Contract. The Board shall give the TPA prompt notice in writing of any
action or suit filed and prompt notice of any claim made against the Board by any entity that
may result in litigation related in any way to this Contract.
27.
INSURANCE
The TPA shall be required to maintain, throughout the term of this Contract, at its own
expense, professional and comprehensive general liability insurance. Such policy of
insurance shall provide a minimum coverage in the amount of Five Million Dollars
($5,000,000) per occurrence, Five Million Dollars ($5,000,000) annual aggregate through an
insurance company licensed by the Mississippi Department of Insurance. The TPA shall
annually provide the Board a current Certificate of Insurance.
28.
TPA PERSONNEL
The Board shall, throughout the life of the contract, have the right of reasonable rejection and
approval of staff or Subcontractors assigned to the work by the TPA. If the Board reasonably
rejects staff or Subcontractors, the TPA must provide replacement staff or Subcontractors
satisfactory to the Board in a timely manner and at no additional cost to the Board. The dayto-day supervision and control of the TPA’s employees and Subcontractors is the sole
responsibility of the TPA. The TPA agrees that it shall register and participate in the status
verification system for any new employees hired on or after January 1, 2012, the effective
date of this Contract, to perform work under this Contract for and within the State of
Mississippi.
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29.
RECOVERY OF MONEY
Whenever, under the contract, any sum of money shall be recoverable from or payable by the
TPA to the Board, the same amount may be deducted from any sum due to the TPA under
the contract or under any other contract between the TPA and the Board. The rights of the
Board are in addition and without prejudice to any other right the Board may have to claim
the amount of any loss or damage suffered by the Board on account of the acts or omissions
of the TPA.
30.
APPROVAL
It is understood that this Contract is void and no payment shall be made in the event that the
Mississippi Personal Service Contract Review Board does not approve this Contract.
31.
MISSISSIPPI PUBLIC RECORDS ACT / CONFIDENTIALITY OF CONTRACT
This Contract, including any accompanying exhibits, attachments, and appendices, is subject
to the "Mississippi Public Records Act of 1983," codified as Section 25-61-1 et seq.,
Mississippi Code Annotated and exceptions found in Section 79-23-1 of the Mississippi
Code Annotated (1972, as amended). In addition, this Contract is subject to the provisions of
the Mississippi Accountability and Transparency Act of 2008 (MATA), codified as Section
31-7-13 of the Mississippi Code Annotated (1972, as amended). Unless exempted from
disclosure due to a court-issued protective order, this Contract is required to be posted to the
Department of Finance and Administration’s independent agency contract website for public
access. Prior to posting the Contract on the website, any information identified by the PBM
as trade secrets, or other proprietary information including confidential vendor information,
or any other information which is required confidential by state or federal law or outside the
applicable freedom of information statutes will be redacted.
32.
NOTICE
All notices given pursuant to this Contract shall be in writing and be personally delivered or
mailed with postage prepaid, by registered or certified mail, return receipt requested, to the
address set forth below or such other address as a party may from time to time specify in
writing to the other party. Notice shall be deemed given when actually received or when
refused. The parties agree to promptly notify each other, in writing, of any change in address.
The addresses to which notices are initially to be sent are as follows:
1.
If to the Board:
Executive Director
Department of Finance and Administration
Post Office Box 267
Jackson, Mississippi 39205
Facsimile No: (601) 359-2405
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with a copy of any notice to:
State Insurance Administrator
Office of Insurance
Department of Finance and Administration
P. O. Box 24208
Jackson, Mississippi 39225-4208
Facsimile No: (601) 359-6568
2.
33.
If to TPA:
_____________________________
_____________________________
_____________________________
_____________________________
INCORPORATION OF DOCUMENTS
a.
This Contract consists of and precedence is hereby established by the order of the
following documents incorporated herein:
i. This Contract signed by the parties including Exhibit ____, “Third Party
Medical Claims Administration Services Administrative Fees”; Exhibit ____,
“Third Party Medical Claims Administration Services”; Exhibit ____,
“Performance Standards and Liquidated Damages”; Exhibit ____, “Third
Party Medical Claims Administration Services Vendor Reports”; and Exhibit
____, “Third Party Medical Claims Administration Services Maintenance of
Records”.
ii. The State of Mississippi’s Request for Proposals for Third Party Medical
Claims Administration Services dated December 20, 2010 attached hereto as
Exhibit ____ and incorporated fully herein by reference; and
iii. The TPA’s response to the Request for Proposal dated ______, 2011 attached
hereto as Exhibit ____ and incorporated fully herein by reference.
b.
The terms of the Third Party Medical Claims Administration Services Contract shall
control in the event there is a conflict between the terms of the Third Party Medical
Claims Administration Services Contract, Request for Proposal for Services, or
TPA’s Response to Request for Proposal.
c.
The intent of the above documents which comprise this Contract is to
include all items necessary for the proper execution and performance of the services
provided by the TPA as identified in this Contract.
d.
No delay or omission by the Board in exercising any right, power, or remedy
hereunder or otherwise afforded by law or in equity shall constitute acquiescence on
its part, impair any other right, power, or remedy in this Contract or otherwise by any
2010 State and School Employees Health Insurance Management Board TPA RFP
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means, operate as a waiver of such right, power, or remedy. Failure by the Board at
any time to enforce the provisions of this Contract shall not be construed as a waiver
of any such provisions. Such failure to enforce shall not affect the validity of this
Contract or any part thereof or the right of the Board to enforce any provision at any
time in accordance with its terms. No waiver by the Board to this Contract shall be
valid unless set forth in writing by the Board. No waiver of, or modification to, any
term or condition of this Contract will void, waive, or change any other term of
condition. No waiver by the Board of a default by the TPA will imply, or be
construed, or require waiver of future or other defaults.
34.
FAILURE TO ENFORCE
Failure by the Board at any time to enforce the provisions of the Contract shall not be
construed as a waiver of any such provisions. Such failure to enforce shall not affect the
validity of the Contract or any part thereof or the right of the Board to enforce any provision
at any time in accordance with its terms.
35.
PERFORMANCE BOND
The TPA shall provide a performance bond to guarantee timely and complete establishment
of the TPA services in the amount of three million dollars ($3,000,000) naming the Board as
exclusive beneficiary.
Any failure of the TPA to perform timely and complete
implementation of the TPA services shall result in damages recoverable by the Board against
the TPA’s performance bond. Upon the Board’s agreement that the implementation of the
TPA services is complete, the performance bond shall be released.
36.
FIDELITY BOND
The TPA will maintain a blanket fidelity bond in the amount of two million dollars
($2,000,000) with the Board named as exclusive beneficiary for the duration of this Contract.
Pursuant to such bond, any losses incurred by the Board due to theft or dishonesty of a TPA
employee shall be fully repayable to the Board. The TPA shall be responsible for procuring
any such recovery and reimbursing the Board accordingly.
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THIRD PARTY MEDICAL CLAIMS ADMINISTRATIVE SERVICES CONTRACT
BUSINESS ASSOCIATE STATEMENT
This Business Associate Statement (“BA Statement”) supplements and is made part of the Third
Party Medical Claims Administrator Administrative Services Contract (“Contract”) entered into by
and between ___________________________ (“Business Associate”) and the State and School
Employees Health Insurance Management Board (the “Board”) and shall apply to the Business
Associate’s services provided pursuant to the Contract relating to the State and School Employee’s
Health Insurance Plan (“Covered Entity”). The effective date of this BA Statement shall be
_____________________.
Whereas, the Board and Business Associate have entered into the Contract, and whereas the parties
are entering into this BA Statement to satisfy certain standards and requirements of the Health
Insurance Portability and Accountability Act of 1996, Public Law 104-191 (“HIPAA”) and
regulations promulgated thereunder by the U.S. Department of Health and Human Services (“HHS”)
(the “HIPAA Regulations”) and other applicable laws, including the American Recovery and
Reinvestment Act (“ARRA”) of 2009.
Whereas, the Covered Entity wishes to disclose certain information (“Information”) to Business
Associate pursuant to the terms of the Contract, some of which may constitute Protected Health
Information (“PHI”).
Whereas, the Covered Entity desires and directs Business Associate to share PHI with other Business
Associates of the Covered Entity.
Therefore, in consideration of mutual promises below and exchange of information pursuant to this
BA Statement, the parties agree as follows:
1.
Definitions.
Terms used, but not otherwise defined, in this BA Statement shall have the same meaning as those
terms in the Standards for Privacy of Individually Identifiable Information (the “Privacy Rule”) and
the Security Standards under the Health Insurance Portability and Accountability Act of 1996
(“HIPAA”). In the event of an inconsistency between the provisions of this BA Statement and
mandatory provisions of the Privacy Rule and or the Security Standards, as amended, the Privacy
Rule and/or the Security Standards shall control. Where provisions of this BA Statement are different
than those mandated in the Privacy Rule and/or the Security Standards, but are nonetheless permitted
by the Privacy Rule and/or the Security Standards, the provisions of this BA Statement shall control.
a.
Breach. Breach shall be as defined in HITECH and the HIPAA regulations at 45 CFR
§ 164.402.
b.
Business Associate. Business Associate shall have the meaning given to such term
under the HIPAA Regulations, including, but not limited to, 45 CFR §160.103.
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c.
Covered Entity. Covered Entity shall have the same meaning given to such term under
the HIPAA Regulations, including, but not limited to, 45 CFR § 160.103.
d.
Electronic Health Record. Electronic Health Record shall have the same meaning as
the term “electronic health record” in the Health Information Technology for
Economic and Clinical Health Act (“HITECH” Act), which is an electronic record of
health-related information on an individual that is “created, gathered, managed and
consulted by authorized health care clinicians and staff”.
e.
Electronic Media. Electronic Media has the same meaning as the term “electronic
media” in 45 in CFR § 160.103, which is:
i.
Electronic storage media including memory devices in computers (hard drives)
and any removable/transportable digital memory medium, such as magnetic tape
or disk, optical disk, or digital memory card; or
ii.
Transmission media used to exchange information already in electronic storage
media. Transmission media include, for example, the internet (wide-open),
extranet (using internet technology to link a business with information accessible
only to collaborating parties), leased lines, dial-up lines, private networks, and
the physical movement of removable/transportable electronic storage media.
Certain transmissions, including of paper, via facsimile, and of voice, via
telephone, are not considered to be transmissions via electronic media because
the information being exchanged did not exist in electronic form before the
transmission.
f.
Electronic Protected Health Care Information or (EPHI). EPHI has the same meaning
as the term ‘electronic protected health care information’ in 45 CFR § 160.103, and is
defined as that received from or received on behalf of the Covered Entity.
g.
Individual. Individual shall have the same meaning as the term “individual" in 45
CFR § 164.501 and shall include a person who qualifies as a personal representative in
accordance with 45 § CFR 164.502(g).
h.
Privacy Rule. Privacy Rule shall mean the Standards for Privacy of Individually
Identifiable Health Information at 45 § CFR part 160 and part 164, subparts A and E.
i.
Protected Health Information or (PHI). PHI shall have the same meaning as the term
“protected health information" in 45 CFR § 164.103, limited to the information created
or received by Business Associate from or on behalf of the Covered Entity.
j.
Required By Law. Required By Law shall have the same meaning as the defined term
“required by law” in 45 § CFR 164.103 except the term “entity” therein shall be
replaced with “business associate” or “person,” as applicable.
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2.
k.
Security Incident has the meaning in 45 CFR § 164.304, which is: the attempted or
successful unauthorized access, use, disclosure, modification, or destruction of
information or interference with system operations in an information system.
l.
Security Standards shall mean the Security Standards under the Health Insurance
Portability and Accountability Act of 1996 (HIPAA) codified at 45 CFR Parts 160 and
164 (Security Rule).
m.
Unsecured PHI as defined in HIPAA and the HIPAA regulations at 45 CFR § 164.402,
means protected health information that is not rendered unusable, unreadable, or
indecipherable to unauthorized individuals through the use of technology or
methodology specified by the Secretary in guidance issued under 13402(h)(2) of
Public Law 111-5 on HHS website.
Obligations and Activities of Business Associate.
a.
Compliance with Applicable Laws. Business Associate shall fully comply with the
standards and requirements of the Health Insurance Portability and Accountability Act
of 1996, Public Law 104-191 (“HIPAA”), the American Recovery and Reinvestment
Act of 2009, Public Law 111-5 (“ARRA”) and regulations promulgated thereunder by
the U.S. Department of Health and Human Services (the “HIPAA Regulations”) and
other applicable laws as of the date(s) the requirements under these laws become
effective for Business Associates. This compliance shall include all requirements
noted in Section 13404(a), (b) and (c) of the HITECH Act.
b.
Business Associate directly subject to certain HIPAA provision. Under HITECH,
Business Associates acknowledges that it is directly subject to certain HIPAA
provisions including, but not limited to, Sections 13401, 13404, 13405 of HITECH.
c.
Use and Disclosure of Protected Health Information. Business Associate may use
and/or disclose the Covered Entity’s PHI received by Business Associate pursuant to
this BA Statement, the Contract, or as required by law, or as permitted under 45 CFR §
164.512, subject to the provisions set forth in this BA Statement. Business Associate
may use PHI in its possession for its proper management and administration or to
fulfill any of its legal responsibilities. The Covered Entity specifically requests that
Business Associate disclose PHI to other Business Associates of the Covered Entity
for Health Care Operations of the Covered Entity. The Covered Entity shall provide a
list of the affected Business Associates and will request specific disclosures in written
format. If any affected Business Associate is no longer under a BA Statement with the
Covered Entity, the Covered Entity shall promptly inform Business Associate of such
change.
d.
Safeguards Against Misuse of Information. Business Associate shall use appropriate
safeguards to prevent the use or disclosure of the Covered Entity’s PHI in any manner
other than as required by this BA Statement or as required by law. Business Associate
shall maintain a comprehensive written information privacy and security program that
includes administrative, technical, and physical safeguards appropriate to the size and
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complexity of the Business Associate’s operations and the nature and scope of its
activities.
e.
Reporting of Disclosures. Business Associate shall report to the Covered Entity any
use or disclosure of the Covered Entity’s PHI in violation of this BA Statement or as
required by law of which the Business Associate is aware, and agrees to mitigate, to
the extent practicable, any harmful effect that is known to Business Associate of a use
or disclosure of the Covered Entity’s PHI by Business Associate in violation of this
BA Statement.
f.
Business Associate’s Agents. Business Associate shall ensure that any agents,
including subcontractors, to whom it provides PHI received from (or created or
received by Business Associate on behalf of) the Covered Entity agree to be bound to
by the same restrictions and conditions on the use or disclosure of PHI as apply to
Business Associate with respect to such PHI. Business Associate represents that in the
event of a disclosure of PHI to any third party, the information disclosed shall be in a
limited data set if practicable and in all other cases the minimum amount of PHI
necessary to accomplish the intended purpose of the use, disclosure or request.
g.
Nondisclosure. Business Associate shall not use or further disclose the Covered
Entity’s PHI otherwise than as permitted or required by this BA Statement, the
Contract, or as required by law.
h.
Availability of Information to the Covered Entity and Provision of Access and
Accountings. Business Associate shall make available to the Covered Entity such
information as the Covered Entity may require to fulfill the Covered Entity’s
obligations to provide access to, provide a copy of, and account for disclosures with
respect to PHI pursuant to HIPAA and the HIPAA Regulations, including, but not
limited to, 45 CFR §§ 164.524 and 164.528, and the HITECH Act. This availability
includes information related to disclosures of an electronic health record made for
treatment, payment or healthcare operations. Business Associate agrees to provide
access, at the request of the Covered Entity, and in the time and manner designated by
the Covered Entity, to Protected Health Information to the Covered Entity or, as
directed by the Covered Entity, to an Individual in order to meet the requirements
under 45 CFR § 164.524. As requested by the Covered Entity, Business Associate
shall produce an accounting of disclosures to an Individual in accordance with 45 CFR
§ 164.528. [45 CFR § 164.504(e)(2)(E) and (G)]
i.
Amendment of PHI. Business Associate shall make the Covered Entity’s PHI
available to the Covered Entity as the Covered Entity may require to fulfill the
Covered Entity’s obligations to amend PHI pursuant to HIPAA and the HIPAA
Regulations, including, but not limited to, 45 CFR § 164.526 and Business Associate
shall, as directed by the Covered Entity, incorporate any amendments to the Covered
Entity’s PHI into copies of such PHI maintained by Business Associate. Business
Associate agrees to make any amendment(s) to Protected Health Information that the
Covered Entity directs or agrees to pursuant to 45 CFR § 164.526 at the request of the
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Covered Entity or an Individual, and in the time and manner designated by the
Covered Entity. [45 CFR § 164.504(e)(2)(F)]
j.
Internal Practices. Business Associate agrees to make its internal practices, policies,
procedures, books, and records relating to the use and disclosure of PHI received from
the Covered Entity (or received by Business Associate on behalf of the Covered
Entity) available to the Secretary of the U.S. Department of Health and Human
Services for inspection and copying for purposes of the determining the Covered
Entity's compliance with HIPAA and the HIPAA Regulations.
k.
Notification of Breach. During the term of this BA Statement, Business Associate
shall notify the Covered Entity within twenty-four (24) hours of any suspected or
actual breach of security, intrusion or unauthorized use or disclosure of PHI and/or any
actual or suspected use or disclosure of data in violation of any applicable federal or
state laws or regulations. Business Associate shall take (i) prompt corrective action to
cure any such deficiencies and (ii) any action pertaining to such unauthorized
disclosure required by applicable federal and state laws and regulations. Under certain
circumstances, Business Associate shall notify the HHS and the media as required by
ARRA under Title XIII, Health Information Technology for Economic and Clinical
Health Act (“HITECH”).
l.
Safeguard of EPHI. The Business Associate will implement administrative, physical,
and technical safeguards that reasonably and appropriately protect the confidentiality,
integrity, and availability of the Electronic Protected Health Information that it creates,
receives, maintains, or transmits on behalf of the Covered Entity.
m.
Subcontractors. The Business Associate will ensure that any agent, including a
subcontractor, to whom it provides PHI agrees to implement reasonable and
appropriate safeguards to protect it.
n.
Notification. The Business Associate will report to the Covered Entity through the
Mississippi Department of Finance and Administration, Office of Insurance any
Breach of Unsecured PHI of which it becomes aware, without unreasonable delay, in
the following time and manner:
i. any actual, successful Security Incident will be reported to the Covered Entity
in writing, within five (5) business days of the date on which Business
Associate becomes aware of such actual successful Security Incident; and
ii. any attempted, unsuccessful Security Incident, of which Business Associate
becomes aware, will be reported to the Covered Entity in writing, on a
reasonable basis, at the written request of the Covered Entity. If the Security
Rule is amended to remove the requirement to report unsuccessful attempts at
unauthorized access, this subsection (ii) shall no longer apply as of the
effective date of the amendment of the Security Rule.
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Business Associate shall maintain and provide to the Covered Entity within ten (10)
business days of a Breach of Unsecured PHI, (as these terms are defined by HITECH),
the appropriate information to allow the Covered Entity to adhere to Breach
notification.
The information provided to the Covered Entity must include, at a minimum, the
following information, to the extent possible:
i. A brief description of what happened, including the date of the breach and the
date of the discovery of the breach, if known.
ii. A description of the types of unsecured protected health information that were
involved in the breach (such as full name, Social Security number, date of
birth, home address, account number, or disability code).
iii. The steps individuals should take to protect themselves from potential harm
resulting from the breach.
iv. A brief description of what the Covered Entity involved is doing to investigate
the breach, to mitigate losses, and to protect against any further breaches.
Such notice shall include the information required by 45 CFR § 164.410(c).
3.
o.
Minimum Necessary. Business Associate shall limit its uses and disclosures of, and
requests for , PHI (a) when practical, to the information making up a Limited Data Set;
and (b) in all other cases subject to the requirements of 45 CFR § 164.502(b), to the
minimum amount of PHI necessary to accomplish the intended purpose of the use,
disclosure or request.
p.
Marketing. Business Associate will not sell PHI or use or disclose PHI for purposes
of marketing, as defined and proscribed in the Regulations.
q.
Data Aggregation. Business Associate may use PHI in its possession to provide data
aggregation services relating to the health care operations of the Covered Entity, as
provided for in 45 CFR §164.501.
r.
De-identification of PHI. Business Associate may de-identify any and all PHI,
provided that the de-identification conforms to the requirements of 45 CFR §
164.514(b), and further provided that Business Associate maintains the documentation
required by 45 CFR § 164.514(b), which may be in the form of a written assurance
from Business Associate. Pursuant to 45 CFR § 164.502(d), de-identified information
does not constitute PHI and is not subject to the terms of the BA Statement.
Obligations of the Covered Entity
a.
Covered Entity’s Representatives. The Covered Entity shall designate, in writing to
Business Associate, individuals to be regarded as the Covered Entity’s representatives,
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so that in reliance upon such designation Business Associate is authorized to make
disclosures of PHI to such individuals or to their designee(s).
4.
b.
Restrictions on Use or Disclosure of PHI. If the Covered Entity agrees to restrictions
on use or disclosure, as provided for in 45 CFR § 164.522 and the HITECH Act, of
PHI received or created by Business Associate regarding an Individual, the Covered
Entity agrees to pay Business Associate the actual costs incurred by Business
Associate in accommodating such voluntary restrictions.
c.
Limitation on Requests. The Covered Entity shall not request or require that Business
Associate make any use or alteration of PHI that would violate HIPAA or HIPAA
Regulations if done by the Covered Entity.
Audits, Inspection, and Enforcement.
Upon reasonable notice, upon a reasonable determination by the Covered Entity that Business
Associate has breached this BA Statement, the Covered Entity may inspect the facilities,
systems, books and records of Business Associate to monitor compliance with this BA
Statement. Business Associate shall promptly remedy any violation of any term of this BA
Statement and shall certify the same to the Covered Entity in writing. The fact that the
Covered Entity inspects, or fails to inspect, or has the right to inspect, Business Associate’s
facilities, systems and procedures does not relieve Business Associate of its responsibility to
comply with this BA Statement, nor does the Covered Entity’s (i) failure to detect or (ii)
detection, but failure to notify Business Associate or require Business Associate’s remediation
of any unsatisfactory practices constitute acceptance of such practice or a waiver of the
Covered Entity’s enforcement rights under this BA Statement. Business Associate shall fully
cooperate with the U.S. Department of Health and Human Services, as the primary enforcer of
the HIPAA, who shall conduct periodic compliance audits to ensure that both Business
Associate and the Covered Entity are compliant.
5.
Termination.
a.
b.
Material Breach. A breach by Business Associate of any provision of this BA
Statement, as determined by the Covered Entity, shall constitute a material breach of
the BA Statement and shall provide grounds for immediate termination of the BA
Statement and the Contract by the Covered Entity pursuant to Section 5.b. of this BA
Statement. [45 CFR § 164.504(e)(3)]
Reasonable Steps to Cure Breach. If either Party knows of a pattern of activity or
practice of the other that constitutes a material breach or violation of that Party’s
obligations under the provisions of this BA Statement or another arrangement and
does not terminate this BA Statement pursuant to Section 5(a), then that Party shall
take reasonable steps to cure such breach or end such violation, as applicable. If the
Party’s efforts to cure such breach or end such violation are unsuccessful, that Party
shall either (i) terminate this BA Statement if feasible; or (ii) if termination of this BA
Statement is not feasible, the non-breaching Party shall report the other Party’s breach
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or violation to the Secretary of the Department of Health and Human Services. [45
CFR § 164.504(e)(1)(ii)]
6.
c.
Judicial or Administrative Proceedings. Either party may terminate this BA
Statement, effective immediately, if (i) the other party is named as a defendant in a
criminal proceeding for a violation of HIPAA or (ii) a finding or stipulation that the
other party has violated any standard or requirement of HIPAA or other security or
privacy laws is made in any administrative or civil proceeding in which the party has
been joined.
d.
Effect of Termination. Upon termination of this BA Statement and the Contract for
any reason, Business Associate shall return or destroy all PHI received from the
Covered Entity (or created or received by Business Associate on behalf of the Covered
Entity) that Business Associate still maintains in any form, and shall retain no copies
of such PHI except for one copy that Business Associate will use solely for archival
purposes and to defend its work product, provided that documents and data remain
confidential and subject to this BA Statement, or, if return or destruction is not
feasible, it shall continue to extend the protections of this BA Statement to such
information, and limit further use of such PHI to those purposes that make the return
or destruction of such PHI infeasible. [45 CFR § 164.504(e)(2)(I)]
Disclaimer.
The Covered Entity makes no warranty or representation that compliance by Business
Associate with this BA Statement, HIPAA or the HIPAA Regulations will be adequate or
satisfactory for Business Associate’s own purposes or that any information in Business
Associate’s possession or control, or transmitted or received by Business Associate, is or will
be secure from unauthorized use or disclosure. Business Associate is solely responsible for all
decisions made by Business Associate regarding the safeguarding of PHI.
7.
Amendment.
Amendment to Comply with Law. The parties acknowledge that state and federal laws
relating to electronic data security and privacy are rapidly evolving and that amendment of
this BA Statement may be required to provide for procedures to ensure compliance with such
developments. The parties specifically agree to take such action as is necessary to implement
the standards and requirements of HIPAA, the HIPAA Regulations and other applicable laws
relating to the security or confidentiality of PHI. The parties understand and agree that the
Covered Entity must receive satisfactory written assurance from Business Associate that
Business Associate will adequately safeguard all PHI that it receives or creates pursuant to
this BA Statement. Upon the Covered Entity’s request, Business Associate agrees to
promptly enter into negotiations with the Covered Entity concerning the terms of an
amendment to this BA Statement embodying written assurances consistent with the standards
and requirements of HIPAA, the HIPAA Regulations or other applicable laws. The Covered
Entity may terminate this BA Statement upon 90 days written notice in the event (i) Business
Associate does not promptly enter into negotiations to amend this BA Statement when
requested by the Covered Entity pursuant to this Section; or (ii) Business Associate does not
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enter into an amendment to this BA Statement providing assurances regarding the
safeguarding of PHI that the Covered Entity, in its sole discretion, deems sufficient to satisfy
the standards and requirements of HIPAA and the HIPAA Regulations.
8.
Assistance in Litigation or Administrative Proceedings.
Business Associate shall make itself, and any subcontractors, employees or agents assisting
Business Associate in the performance of its obligations under this BA Statement, available to
the Covered Entity, at no cost to the Covered Entity, to testify as witnesses, or otherwise, in
the event of litigation or administrative proceedings being commenced against the Covered
Entity, its directors, officers or employees based upon claimed violation of HIPAA, the
HIPAA Regulations or other laws relating to security and privacy, except where Business
Associate or its subcontractor, employee or agent is a named adverse party.
9.
No Third Party Beneficiaries.
Nothing express or implied in this BA Statement is intended to confer, nor shall anything
herein confer, upon any person other than the Covered Entity, Business Associate and their
respective successors or assigns, any rights, remedies, obligations or liabilities whatsoever.
10.
Effect on Contract.
Except as specifically required to implement the purposes of this BA Statement, or to the
extent inconsistent with this BA Statement, all other terms of the Contract shall remain in
force and effect.
11.
Electronic Health Records (EHR)
If electronic health records are used or maintained with respect to PHI, individuals shall have
the right to obtain a copy of such information in “electronic format”.
12.
No Remuneration for PHI.
Business Associate shall not directly or indirectly receive remuneration in exchange for any
PHI, unless it first obtains a valid authorization from the individual whose PHI is being
disclosed.
13.
Interpretation.
This BA Statement shall be interpreted as broadly as necessary to implement and comply with
HIPAA, HIPAA Regulations and applicable state laws. The parties agree that any ambiguity
in this BA Statement shall be resolved in favor of a meaning that complies and is consistent
with HIPAA and the HIPAA Regulations.
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