STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION REQUEST FOR INFORMATION AHCA RFI /16

Transcription

1 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION REQUEST FOR INFORMATION AHCA RFI /16 STATEWIDE PROVIDER AND HEALTH PLAN CLAIM DISPUTE RESOLUTION PROGRAM A. GENERAL INFORMATION 1. Purpose This is a Request for Information (RFI) as defined in Section (22), Florida Statutes (F.S.), for planning purposes. This RFI is issued by the State of Florida, Agency for Health Care Administration (Agency), to solicit information regarding available providers for the services described herein. The purpose of this RFI is to determine vendor interest and perspectives about the opportunities in providing independent third party claim dispute resolution to contracted and non-contracted health care providers and health care plans within the parameters of Sections , F.S. and Rule 59A , Florida Administrative Code (FAC). These services are to be provided at no cost to the Agency, and the provider s participation is voluntary. An RFI is not a method of procurement. Responses to an RFI are not offers and shall not be accepted by the Agency to form a binding Contract. This RFI and responses to it shall not result in the execution of a Contract with the Agency. By submitting a response to this RFI, a Vendor is not prohibited from responding to any related subsequent solicitation. This RFI may be used for purposes of determining whether or not to competitively procure a commodity or contractual service, determining what solicitation process to use, or researching general, special, and/or technical specifications for a solicitation. The Agency reserves the right to utilize the information gathered through the RFI process to develop a scope of services, which may be incorporated into a Contract using a statutorily approved method of procurement. AHCA RFI /16, Page 1 of 7

2 2. Background During the 2000 Legislative Session, the Agency was given the authority to contract with a qualified independent third-party claim dispute resolution entity, hereinafter referred to as the resolution organization, to provide assistance to contracted and non-contracted providers and health care plans for resolution of claims disputes within the parameters of Section , F.S. and Rule 59A , FAC. 3. Description of Services The resolution organization shall perform claim dispute review and resolution services within the parameters of Section , F.S. and Rule 59A , FAC. a. The resolution organization shall determine, based on a desk review, the claim disputes submitted by the health care plans, and/or contracted and non-contracted health care providers in accordance with the statutory requirements of Section (2)(b)(c)(d), F.S., and shall determine whether the dispute meets the claim threshold requirements specified in Rule 59A (2)(a)(b)(c), FAC. b. If the resolution organization determines that the request fails to meet statutory and rule requirement, the resolution organization shall return the request to the entity filing the request. If the request meets the requirements, the resolution organization shall issue a written recommendation to the Agency, based on finding of fact, within sixty (60) calendar days after the request is received by the resolution organization. c. The dispute resolution procedure shall entail the review of the documentation provided and any additional information requested by the resolution organization. The resolution organization shall have the capability to research the claim dispute submission and make a recommendation to the Agency, based on findings of fact, within sixty (60) calendar days after the request is received by the resolution organization. d. Based upon the Florida legislation (HB 221), the dispute resolution process must comply with Section (2)(h), F.S., to allow for either the provider or health care plan to make an offer to settle the claim dispute when it submits a request for a claim dispute and supporting documentation. The AHCA RFI /16, Page 2 of 7

3 offer to settle the claim dispute must state its total amount, and the party to whom it is directed has fifteen (15) calendar days to accept the offer once it is received. If the offer to settle the claim dispute is not accepted and the final order is within ten percent (10%) of the offer, the entity that did not accept the offer shall pay the final order amount plus all accrued interest and shall be considered a nonprevailing party for purposes of this section. If the offer to settle the claim dispute is made by the provider, the total amount in the offer to settle the presumed underpayment may not be within ten percent (10%) of the reimbursement amount received by the provider. If the offer to settle the claim dispute is made by the health care plan, the offer to settle the presumed overpayment may not be within ten percent (10%) of the overpayment amount sought from the provider. e. The Agency shall adopt a final order within thirty (30) calendar days after receipt of the recommendations of the resolution organization; the Agency shall adopt the recommendation as a final order. The final order is subject to judicial review pursuant to Section , F.S. f. The written recommendation shall include a recommendation to the Agency that the defaulting entity shall pay the entity submitting the claim dispute the full amount of the claim dispute, plus all accrued interest, and shall be considered a nonprevailing party pursuant to Section (2)(f), F.S. B. INFORMATION REQUESTED 1. Respondents are requested to provide information specified in Section C., RFI Response Instructions of this RFI for the following requirements of the resolution organization: a. Shall operate and maintain an independent third-party claim-dispute resolution program through a no cost contract. The Vendor may collect review fees from the participating parties. b. Shall be a qualified independent third-party claim-dispute resolution entity as outlined in Section (1)(c), F.S.; c. Shall have the staff necessary to perform a timely and qualified review of submitted claim disputes; d. Shall have the capability to complete the review within sixty (60) calendar days after the requested information is received by the resolution organization and not to exceed ninety (90) calendar days after receipt of the initial claim submission as outlined in Section (g)(3) F.S.; AHCA RFI /16, Page 3 of 7

4 e. Shall be available to review and process cases on an as needed basis. The number of dispute cases submitted cannot be anticipated; f. Shall be registered as a State of Florida Vendor. Vendor Registration can be accomplished online at g. Shall be registered to do business in the State of Florida through the Florida Department of State s Division of Corporations. Vendor registration can be accomplished online at and h. Shall comply with the Department of Health and Human Services Privacy Regulations specified in the Code of Federal Regulations, Title 45, Section 160 and 164 regarding the Health Insurance Portability and Accountability Act (HIPPA). C. RFI RESPONSE INSTRUCTIONS Respondents to this RFI are asked to be thorough, but concise. The RFI response should include the following. 1. The Respondents name; place of business address(s); contact information, including representative name and alternate, if available; telephone number(s) and address(s). 2. A statement of interest in the proposed services outlined in this RFI. 3. A description of the Respondent s business and its experience including accreditation or certification as it relates to the services outlined in this RFI. This description should include a narrative explaining past experiences in which the Respondent has reviewed claim disputes involving contracted and non-contracted providers and the health care plan. 4. A description of the Respondent s program specifications, including information on the Respondent s approach for review of cases and recommendations; and ability to share data with the Agency. 5. A description of the Respondent s protocols and internal procedures for ensuring system security and the confidentiality of personally identifiable data, as well as its disaster recovery plan and ability to resume service with minimal disruption. AHCA RFI /16, Page 4 of 7

5 6. Information with regard to proposed staffing, including: Number of proposed staff and designation of full time staff; Responsibilities of staff by position; Resumes for proposed staff; Training requirements; and Background screening criteria utilized for hiring. 7. A description of the Respondent s quality assurance system, including a description of how the Respondent intends to monitor the appropriateness and effectiveness of the service; 8. The Respondent s fee schedule, which includes the charge per hour for necessary services which may include: Physician expert review; Utilization nurse review; Medical claims coding expert review; Legal expert review; Initial review to determine eligibility; and Any other possible review fees. The Respondent s background and experience in tasks that are similar to the tasks required by Section , F.S. and Rule 59A , FAC, including, but not limited to: References; Dispute resolution experience; Dispute resolution experience related to health care issues; AHCA RFI /16, Page 5 of 7

6 Dispute resolution experience related to HMO and provider disputes; Dispute resolution experience related to HMO and subscriber disputes; Experience in health care financing; Experience in coding of medical claims; and Corporate personnel, computer, and other resources. D. PROPRIETARY INFORMATION Any portion of the submitted response which is asserted to be exempt from disclosure under Chapter 119, Florida Statutes, shall be clearly marked exempt, confidential, or trade secret (as applicable) and shall also contain the statutory basis for such claim on every page. Pages containing trade secrets shall be marked trade secret as defined in Section , Florida Statutes. Failure to segregate and identify such portions shall constitute a waiver of any claimed exemption and the Agency will provide such records in response to public records requests without notifying the Respondent. Designating material simply as proprietary will not necessarily protect it from disclosure under Chapter 119, F.S. An entire response should not be considered trade secret. E. RESPONSE SUBMISSION Respondents to this RFI shall submit one (1) electronic copy of its response. The response shall not exceed one hundred (100), single-sided, pages in length. The electronic format shall be submitted on CD-ROM. The software used to produce the electronic files must be Microsoft Word 2013 and/or Excel 2013 or newer. The electronic files must be logically named. The respondent shall also submit one (1) electronic redacted copy of the response suitable for release to the public. Any confidential or trade secret information covered under Section , Florida Statutes, should be either redacted or completely removed. The redacted response shall be marked as the redacted copy and contain a transmittal letter authorizing release of the redacted version of the response in the event the Agency receives a public records request. Responses to this RFI shall be provided no later than 5:00 PM, Eastern Standard Time, May 2, Responses shall be submitted to: AHCA RFI /16, Page 6 of 7

7 Agency for Health Care Administration Procurement Office Attn: Victoria Bell 2727 Mahan Drive, MS 15 Tallahassee, FL After the Agency has received all responses to this RFI, the Agency, in its sole discretion, shall determine if a meeting with respondents is necessary to clarify the information received. In the event that the Agency decides to hold a meeting, the Respondents(s) will be notified via . F. VENDOR COSTS Vendors are responsible for all costs associated with preparing a response to this RFI. The State of Florida, Agency for Health Care Administration, will not be responsible for any vendor costs associated with preparing a response to this RFI. G. QUESTIONS Questions concerning this RFI should be submitted in writing via to procurement@ahca.myflorida.com All responses to questions received will be made, in writing, directly to the sender. H. AGENCY FOR HEALTH CARE ADMINISTRATION WEBSITE Additional information about the Florida Agency for Health Care Administration can be found on the Agency s website at: AHCA RFI /16, Page 7 of 7