HHS IHS RFQ: Claims Processing & Eligibility Services, Software, License and PM Services

Notice ID: IHS1493005

Vendor shall provide technology that streamlines the current Medicare, Medicaid, Private Insurance and Veterans Administration claims processes and eligibility at Crownpoint Comprehensive Health Care, Crownpoint, New Mexico. As the patient population grows and payer requirements change, and costs associated with submitting claims on paper increases and/or payers are phasing out paper claim submissions, Crownpoint’s reimbursement from these payers is in constant jeopardy.  As more Native Americans are enrolled in Medicare, Medicaid and Private Insurance programs and that many Medicaid payers are moving to HMO models, the need to verify eligibility for these programs in real time will enhance and streamline this process that historically has been time consuming and as a result, lost potential third-party revenue.  Having eligibility captured at the point-of-service has cut down on overtime costs, reduce the need for follow-up on denied claims and increase revenue.

PURPOSE:   Crownpoint Comprehensive Health Care requires continued use of a software application that provides secure exchange of payer electronic claims and eligibility verification system for all patient inquiries. Based on HIPAA requirements and IHS Headquarter mandates, it is required to have all transactions secure, managed, exchanged, and to be in HIPAA compliance.

DESCRIPTION OF SERVICES/SUPPLIES:  Vendor Shall provide certain and exclusive efficiencies with respect to electronic claims workflow and eligibility within a secure, private, and electronic format with a single sign on. To provide a software application that provides a secure exchange of third-party patient insurance claims, patient eligibility information and access with confidentiality, authentication, integrity, and non-repudiation for the Crownpoint Comprehensive Health Care in accordance with the Statement of Work. Services provided serves as a means of enhancing and maximizing revenue, collection activities and meeting payer 837 requirements.  The contractor has the ability to provide a high value to healthcare providers who are seeking efficiencies and cost savings in their electronic claim’s submission with Medicare, Medicaid, thousands of commercial payers and Veterans Administration.  Vendor shall deliver software as a service. Vendor’s software shall not directly interact with RPMS, meaning Vendor shall not reach into that system, no true integration. Users are logging into our secure web portal instead of Vendor shall being integrated with RPMS. The vendor will enable claims management software is using Amazon Web Services, however, and is FedRamp certified.

DELIVERABLES:    Vendor shall provide internet-based connectivity for 837 electronic claim submission and provide real-time, point-of-service eligibility data from HIPAA Eligibility Transaction System (HETS) along with other payers through vendor’s secured web portal along with necessary training and support. All information will be secured and available for reference to all credentialed users.  The Business Office will maintain user list and restrict personnel to need to know functions within the vendor’s software.

Task #1 – Vendor shall provide claims management on one platform – Vendor shall provide a secure data transport service between Crownpoint Comprehensive Health Care, Medicare, Medicaid, Private Insurance, Veterans Administration and clearinghouses. This service shall comply with the following constraints:

• The service shall require Crownpoint Comprehensive Health Care to install/update contractor software with the Crownpoint Comprehensive Health Care environment.
• The service shall enable Crownpoint Comprehensive Health Care/payer data /exchanges utilizing Vendor Sell as approved by the Indian Health Service Office of Information Technology. The service shall support EDI transactions/reports: 270/271, 837/835, and 997 acknowledge reports.
• The service shall support multiple users, access and access shall be workstation independent…

Task #2 – Maintenance and Support – Vendor shall support end-to-end communication testing, implementation and daily operations of the data transfers from payers to Crownpoint Comprehensive Health Care, which shall include, at a minimum:

• 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.
• The contractor shall notify a designated Crownpoint Comprehensive Health Care point of contact or Contracting Officer’s Technical Representative (COTR) of any scheduled maintenance that shall result in downtime at least (2) days prior to the maintenance period…

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