Statement of Work (SOW)
For the Wagner Health Care Center
Insurance Verification – Clearinghouse Services
Background:
The Mission of the Wagner Health Care Center is to provide the best possible healthcare services to the patients on the Yankton Sioux Reservation in South Dakota. To meet this mission, the WHCC is requesting a Base Plus Four (4) Option Year, firm-fixed price, non-personal service contract to provide insurance verification and patient eligibility services.
Objective:
The Wagner Health Care Center requires a secure exchange data software solution to provide connectivity to the Medicare DDE (Direct Data Entry)/FISS (Fiscal Intermediary Standard System), eligibility verification, and eligibility searches.
The contractor will perform third party insurance medical claims validation, electronic claim processing via clearinghouse services for Medicare, Medicaid, VA and Commercial Payers for the Wagner Health Care Center
Work Schedule/Availability
WHCC hours of operations are Monday through Sunday 7:00am to 11:00pm.
Period of Performance
Base year: One Year from Date of Award
Option Year 1: 06/26/2026 to 06/25/2027
Option year 2: 06/26/2027 to 06/25/2028
Option Year 3: 06/26/2028 to 06/25/2029
Option Year 4: 06/26/2029 to 06/25/2030
Place of Performance
Wagner Health Care Center
111 Washington Ave. NW
Wagner, South Dakota 57380
Scope
The contractor shall provide a secure exchange data software solution that provides technology for:
- Connectivity to the Medicare DDE (Direct Data Entry) /FISS (Fiscal Intermediary Standard System) and automated claims status reporting, payment floor details and other reports
- Eligibility verification for third party payers to include Medicare
- Eligibility results must include start and end dates of coverage
- Capability to search eligibility for third party coverage for patients
- Third party insurance medical electronic claims submission via a clearinghouse for Medicare, Medicaid, VA and Commercial Payers for the Wagner Health Center
- Electronic claim submission of all claim types: Outpatient and Specialty Clinics; and provide both solicited and unsolicited claims status
- The software must provide rigorous and thorough claims rules and custom business rules
- Capability for self-monitoring usage of services for thresholds
- Training and support related to scope of work – training provided either on-site or via teleconference
The software services shall comply with the following constraints:
- The software service shall not require Wagner Health Center to install contractor software within the Wagner Health Center or Indian Health Service network.
- The service shall enable Wagner Health Center to exchange data utilizing a Secure File Transfer Protocol (SFTP) as approved by the Indian Health Service Office of Information Technology.
- The service shall support Electronic Data Interchange (EDI) transactions and interactive Telnet application protocol sessions.
- The service shall support unlimited users and access shall be workstation independent.
- The service shall not entail development of Health Insurance Portability and Accountability Act (HIPAA) transaction set translation or mapping processes, non-CMS or non-IHS generated data or messages, or data reformatting.
- The service shall also conform to a Business Associate Agreement to be established between the Wagner Health Care Center and the Contractor.
- The contractor shall support end-to-end communication testing, implementation and daily operations of the data transfers from the contractor to the Wagner Health Care Center, which shall include, at a minimum:
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- The contractor shall provide routine technical support to implement corrections to service occurring as a result of errors, flaws, or other failures within their service.
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- The contractor shall notify a designated Wagner Health Care Center point of contact (Contracting Officer’s Representative (COR)) of any scheduled maintenance that shall result in downtime at least two (2) days prior to the maintenance period.
- The contractor shall notify a designated Wagner Health Care Center point of contact of any issues as that result in a disruption of data exchange capabilities. This notification shall occur as soon as possible after the disruption has been identified.
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- The contractor shall provide customer support for reporting, documenting, tracking and resolving service problems, which shall be available via telephone and email to the Wagner Health Care Center technical staff during the period 8:00 am to 5:00 pm Central Standard Time on weekdays, except government holidays.
- The contractor shall provide capability for self-monitoring usage of services that have a threshold.
Contractor Responsibility
- Secure internet-based connectivity to all current fiscal intermediaries.
- Contractor to send medical emergency, outpatient, and specialty claims to Medicare Contractor and other payers using secure date exchange technology.
- Unlimited Direct Data Entry (DDE) online Medicare claims status/corrections for Medicare Part B.
- All electronic transactions and DDE/FISS shall provide confidentiality, authentication, integrity and non-repudiation.
- Automated batch 837/835 file transfers. Automated batch 276/277 claims status capability.
- Accept electronic claims from Resource Patient Management System (RPMS). Reports and acknowledgements on all claims sent.
- Provide a single secure electronic location to manage all electronic claims, including VA claims. Verify Medicare and Commercial Payer eligibility in real time and batches.
- Provide knowledgeable support personnel to assist with any issues regarding the processing of the medical claims.
- The Contractor shall provide toll free telephone/technical support during normal business hours, 8:00 AM to 5:00 PM, Monday thru Friday, except Government holidays.
- The Contractor shall provide a two (2) hour minimum response time from notification by IHS at no additional cost to the Wagner Health Center.
The medical claim processing services shall meet the following standards:
- After the process of approving claims in the Third-Party Billing package is completed in RPMS. The claims are set up in a file and transmitted/submitted to the appropriate carrier/payer via the Contractor provided clearinghouse by the close of the next business day after receipt from IHS.
- Third party insurance medical claims shall be transmitted electronically to the appropriate carrier/payer.
- The Contractor shall use routine editing procedures to detect defects in medical claims information supplied by the government. The Contractor shall reject and not process all medical claims with defects. The Contractor shall provide the service location with edit status reports listing the defect to aid the service location in the correction of the detected defects.
- The Contractor shall provide for correction all claims rejected by all carriers/payers for any reason other than the inappropriate format to the claims.
- The Contractor shall provide the capability for medical claim errors to be corrected and resubmitted electronically and provide a report of rejected medical claims within 4 hours of batch submission.
- The Contractor shall make available productivity and submission reports within 24 hours of batch transmission.
Contracting Officer’s Representative Designation
The designated COR for this contract is: Dwight Josh Janis
COR Level 1
Wagner Health Care Facility 111 Washington Ave. NW Wagner, SD 57380
The COR is responsible for:
- Monitoring the Contractor’s technical progress;
- Interpreting the statement of work;
- Technical evaluation as required;
- Technical inspections and acceptance required by this contract; and
- Assisting the Contractor in the resolution of technical problems encountered during performance of this contract.
Subject matter expert for this contract is:
Leah Williamson, Billing Technician
Wagner IHS Health Center
111 Washington AVE NW Wagner, South Dakota 57380
Contractor Compliance
The Contractor shall adhere to all official coding and billing rules as published by the American Hospital Association (AHA), Centers for Medicaid and Medicare Services (CMS) regulations and guidelines to ensure the highest levels of integrity compliance and ethics.
The Contractor shall maintain records of confidentiality in accordance with the Health Insurance Portability and Accountability Act (HIPAA), Privacy Act of 1974, Alcohol and Drug Abuse Patient Records, Freedom of Information Act (FOIA), and other pertinent Federal regulations.
Administrative
Compensation – Billing will be at a fixed rate for all services.
Meetings/Conference Calls – The Contractor shall attend meetings or conference calls scheduled by the Contracting Officer’s Representative (COR) to address areas of concern and exchange information to ensure all contract requirements are being met. The COR shall be responsible for scheduling and coordination of all meetings and conference calls.
Equipment Failure – Any delays or downtime due to Contractor equipment failure shall be communicated to the COR or their designee as soon as possible via telephone or email. The Contractor shall not be penalized for delays due to Service Unit equipment failure or updates that are beyond the Contractor’s control (e.g., IHS server downtime).
Government Furnished Property/Equipment/Information
No Government furnished property, equipment, or information is provided.
Reports
The Contractor shall deliver standard or custom reports on demand, to monitor monthly usage of the following:
- Medical Claims Approval
- Eligibility Verification
- Eligibility Searches
- Claims Errors
- Claim Reconciliation
- Additional reports as needed.
