Solicitation 15-050-Revised Clinical Editing Solution

Transcription

CalOptima
Bid 15-050-Revised
5
Solicitation 15-050-Revised
Clinical Editing Solution - Revised
Bid Designation: Public
CalOptima
6
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CalOptima
Bid 15-050-Revised
Bid 15-050-Revised
Clinical Editing Solution - Revised
Bid Number 15-050-Revised
Bid Title Clinical Editing Solution - Revised
Bid Start Date
Jul 23, 2015 7:44:50 AM PDT
Bid End Date
Aug 6, 2015 2:00:00 PM PDT
Bid Contact Kathy Hoppe
5
714-246-8762
khoppe@caloptima.org
Contract Duration 3 years
Contract Renewal 2 annual renewals
Prices Good for 90 days
Bid Comments
Please see RFP 15-050-Revised.
CalOptima is re-releasing RFP 15-050, now entitled "RFP 15-050-Revised," as we have located inaccurate and
incomplete answers to questions posed by Vendors during the original RFP 15-050 process. To those
Offerors that have submitted a proposal resulting from CalOptima's original RFP 15-050, and you find your
proposal will require modifications resulting from the revised answers, please modify your original proposal
by using the Tracking (redline) feature and submitting only those pages with changes. Submittal of the RFP in
its entirety is not recommended.
Other potential Offerors are welcome to submit a proposal, but please understand RFP 15-050-Revised will
not allow for a question/answer period. The questions and revised answers have been uploaded in BidSync as
part of this revised RFP.
Item Response Form
Item 15-050-Revised--01-01 - RFP 15-050 Revised - Clinical Editing Solution
Quantity 1 each
Unit Price Delivery Location CalOptima
City Parkway
505 City Parkway West
Orange CA 92868
Qty 1
Expected Expenditure $1.00 Description
RFP 15-050 Revised - Clinical Editing Solution 6
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CalOptima
Bid 15-050-Revised
July 23, 2015
NOTICE OF REQUEST FOR PROPOSALS (RFP)
15-050 REVISED
GENERAL CONDITIONS AND INSTRUCTIONS TO OFFERORS
for
CLINICAL EDITING SOLUTION
Key RFP Dates
Closing Date: 2:00 p.m. (Pacific Time) August 6, 2015
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CalOptima
Bid 15-050-Revised
July 23, 2015
SUBJECT:
NOTICE OF REQUEST FOR PROPOSALS
Gentlemen/Ladies:
CalOptima invites proposals from qualified Offerors to provide a CLINICAL EDITING SOLUTION.
Proposals shall be prepared and submitted in accordance with the requirements set forth in RFP 15-050
REVISED. The proposals must be submitted via BidSync no later than 12:00 p.m., Pacific Time, Thursday,
August 6, 2015.
Proposals received after the date and time specified above will be rejected by the BidSync program and will
not be delivered to CalOptima.
As required under Ordinance No. 3896 of the County of Orange, State of California, Offeror hereby
acknowledges and agrees that the obligations of CalOptima under any resulting contract are solely the
obligation of CalOptima, and the County of Orange, State of California, shall have no obligation or liability
therefor.
The successful Offeror will be required to comply with all applicable equal opportunity laws and regulations.
Sincerely,
Kathy Hoppe
Kathy Hoppe, CPPB
Contract Administrator
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CalOptima
TABLE OF CONTENTS
Bid 15-050-Revised
Page No.
CalOptima’s Mission Statement and CalOptima Overview .............................................................................................. i
SECTION I: INSTRUCTIONS TO OFFERORS
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
K.
L.
M.
N.
O.
P.
Q.
R.
S.
T.
U.
V.
W.
Examination of Proposal Documents ........................................................................................................................ 1
Addenda ..... ........ ...................................................................................................................................................................... 1
General Information ........................................................................................................................................................... 1
Clarifications .... ...................................................................................................................................................................... 2
1. Examination of Documents ........................................................................................................................................ 2
2. Submitting Requests ..................................................................................................................................................... 2
3. CalOptima Responses.................................................................................................................................................... 2
Submission of Proposals ................................................................................................................................................... 2
1. Date and Time .................................................................................................................................................................. 2
2. Acceptance of Proposals .............................................................................................................................................. 3
Pre-Contractual Expenses ................................................................................................................................................ 3
Joint Offers ........ ...................................................................................................................................................................... 3
Non-Collusion Affidavit ..................................................................................................................................................... 3
Taxes ... ........ ........ ...................................................................................................................................................................... 3
Contract Type and Term ................................................................................................................................................... 3
Prohibited Interest .............................................................................................................................................................. 4
Nondiscrimination Compliance .................................................................................................................................... 4
Federal, State, and Local Laws....................................................................................................................................... 4
Contract Award ...................................................................................................................................................................... 4
Assignment and Subcontractors .................................................................................................................................. 4
Notice of Labor Dispute ..................................................................................................................................................... 5
Disputes ...... ........ ...................................................................................................................................................................... 5
Withdrawal of Offers .......................................................................................................................................................... 5
Strategic and Contract Elements .................................................................................................................................. 5
Use of Offeror Response and Accompanying Material .................................................................................... 6
Excess Re-Procurement Liability ................................................................................................................................ 6
Price Adjustments for Regulatory Changes ........................................................................................................... 6
Bonding………….. ..................................................................................................................................................................... 6
SECTION II: PROPOSAL CONTENT AND FORMS
A. Proposal Format and Content ....................................................................................................................................... 7
1. Presentation ...................................................................................................................................................................... 7
2. Letter of Transmittal ..................................................................................................................................................... 7
3. Technical Proposal ......................................................................................................................................................... 7
4. Proposed Staffing and Project Organization ....................................................................................................... 8
5. Work Plan and Price Schedule .................................................................................................................................. 9
6. Exceptions / Deviations ............................................................................................................................................... 9
7. Appendices ...................................................................................................................................................................... 9
B. Cost and Pricing ..................................................................................................................................................................... 9
C. Payment Terms ................................................................................................................................................................... 10
SECTION III: EVALUATION AND AWARD ................................................................................................................................ 10
SECTION IV: SAMPLE CONTRACT ................................................................................................................................................ 11
SECTION V: SCOPE OF WORK ........................................................................................................................................................ 49
Attachment A: Security Questionnaire ........................................................................................................................................
Attachment B: Additional Information ........................................................................................................................................
Attachment C: Acknowledgement ..............................................................................................................................52
Attachment D: Non-Collusion Affidavit.................................................................................................................................. 55
Attachment E: Request to Negotiate Contract Terms ..............................................................................................
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A.
Bid 15-050-Revised
County Organized Health Systems (COHS) Background
The California State Medicaid (Medi-Cal) program came into existence in March 1966 as a fee-for-service
health care delivery system. In May 1972, Medi-Cal beneficiaries began enrolling in managed care plans when
the first Prepaid Health Plan (PHP) contract went into effect. Joining a PHP was voluntary and limited to those
in a public assistance aid category.
In June 1983, a new type of managed care program, the County Organized Health System (COHS), became
operational. The COHS managed care model ensures Med-Cal recipients access to comprehensive, costeffective health care. Each COHS plan is sanctioned by the County Board of Supervisors and governed by an
independent commission.
The following six California COHS member plans services the primary health delivery system for Medi-Cal
recipients and administer the program for 22 counties:






CalOptima – Orange County;
CenCal Health – San Luis Obispo and Santa Barbara Counties;
Central California Alliance for Health – Merced, Monterey and Santa Cruz Counties;
Gold Coast Health Plan – Ventura County;
Health Plan of San Mateo – San Mateo County and
Partnership Health Plan – Del Norte, Humboldt, Lake, Lassen, Marin, Mendocino, Modoc, Napa,
Shasta, Siskiyou, Solano, Sonoma, Trinity, and Yolo Counties.
The COHS plans were pioneers of a trend toward managed care plans that specialize in serving Medicaid
populations. Specialization allows health plans to develop unique expertise in member outreach and followup, cultural competency, health promotion and disease management to serve low-income members
effectively.
B.
CalOptima Overview
CalOptima is a public agency created by the Orange County Board of Supervisors in August 1993 and began
delivering services to Medical beneficiaries in October 1995 as a COHS. It manages programs that are funded
by the State and Federal governments, but operates independently under the leadership of a Board of
Directors made up of members, providers, business leaders and local government. As of May 31, 2015,
CalOptima’s total membership was 736,958 children and adults.
CalOptima administers health insurance programs for low-income families, children, seniors and persons
with disabilities in Orange County. It is the second largest health insurer in the county and provides coverage
to one in seven residents and almost a third of our community's children through the following major
programs.

Medi-Cal – California's Medicaid Program for low-income families, children, seniors and persons
with disabilities. Medical services are furnished on a fully or partially capitated basis with health
maintenance organizations (HMOs); provider-sponsored organizations known as Physician Hospital
Consortia (PHCs); shared risk groups (SRGs) and a fee-for-service program (CalOptima Direct).
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
OneCare – A Medicare Advantage special needs plan (SNP) HMO and prescription drug for lowincome seniors and persons with disabilities who qualify for both Medicare and Medi-Cal (dual
eligibiles).

OneCare Connect – A program for dual eligible and is planned to replace OneCare (planned
implementation to start no sooner than July 1, 2015).

CalWrap – A Medi-Cal drug plan for dual eligibiles not covered CMC.

Program of All-Inclusive Care for the Elderly (PACE) – An all-inclusive care plan providing
comprehensive health services through the CalOptima PACE center for adults 55 and older, who are
certified as nursing facility level of care (NFLOC).
Our mission is to provide members with access to quality health care services delivered in a cost-effective and
compassionate manner. “Better. Together.” is our motto, but it’s also our philosophy. We believe that by
working together, we can make things better–for our members and community.
CalOptima is the top ranked Medi-Cal plan in California according to the National Committee for Quality
Assurance’s (NCQA’s) Medicaid Health Insurance Plan Rankings for 2014-2015 and ranked 29th in the United
States. CalOptima has also received accreditation with a commendable status from NCQA.
CalOptima’s administrative cost ratio is the fourth lowest (4.74 percent) out of 15 public plans in California
and second lowest among all COHSs. It spends more than 95 cents of every dollar on member care.
CalOptima maintains a strong provider network to serve its nearly 736,958 members, comprising:

1,625 Primary care providers,

5,776 Specialists,

30 Acute and rehabilitation hospitals,

30 Community health centers,

506 Orange County Pharmacies and

103 Long-term care facilities.
Member survey results show that 83 percent of CalOptima members reported satisfaction with physician
interaction and communication. The CalOptima new member orientation was rated as good or excellent by 96
percent of attendees.
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SECTION I.
INSTRUCTIONS TO OFFERORS
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RFP 15-050 REVISED
I. INSTRUCTIONS TO OFFERORS
A.
B.
EXAMINATION OF PROPOSAL DOCUMENTS
1.
By submitting a proposal, the Offeror represents that it has thoroughly examined and
become familiar with the work required under this RFP and that it is capable of performing
quality work to achieve CalOptima’s objectives.
2.
CalOptima reserves the right to remove from its mailing list for future RFPs, for an
undetermined period of time, the name of any Offeror for failure to accept a contract, failure
to respond to two (2) consecutive RFPs and/or unsatisfactory performance. Please note that
a “No Bid” is considered a response.
ADDENDA
CalOptima may make changes to the requirements of this RFP. Any CalOptima changes to the
requirements will be made by written addendum to this RFP. Any written addenda issued pertaining
to this RFP shall be incorporated into the terms and conditions of any resulting contract. CalOptima
will not be bound to any modifications to or deviations from the requirements set forth in this RFP as
the result of oral instruction. All addenda will be mailed to all Offerors.
C.
GENERAL INFORMATION
1.
Scope
CalOptima seeks a competent supplier to provide a Clinical Editing Solution in accordance
with the specifications contained within this Request for Proposal.
2.
CalOptima Point of Contact
The sole point of contact for inquiries concerning this RFP is:
Kathy Hoppe, CPPB
Contract Administrator
CalOptima Vendor Management Department
505 City Parkway West
Orange, CA 92868
(714) 246-8762
khoppe@caloptima.org
All communications relating to this RFP must be directed to the CalOptima contact person
named above. All communications between respondents and other CalOptima staff
members concerning this RFP are strictly prohibited. Failure to comply with these
requirements may result in proposal disqualification.
3.
Procurement Schedule
The following table documents the critical pre-award events for the procurement. All dates
are subject to change at CalOptima’s discretion.
RFP Issue Date…………………………………………………..July 23, 2015
Proposal Due Date……………………………………………..August 6, 2015
Interviews/Site Visits/Reference Checks……………August 17 – 21, 2015
Vendor Selection……………………………………................August 24, 2015
Section I
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RFP 15-050 REVISED
D.
CLARIFICATIONS
CalOptima is re-releasing RFP 15-050, now entitled "RFP 15-050 REVISED," as we have located
inaccurate and incomplete answers to questions posed by Vendors during the original RFP 15-050
process. To those Offerors that have submitted a proposal resulting from CalOptima's original RFP
15-050, and you find your proposal will require modifications resulting from the Revised answers,
please modify your original proposal by using the Tracking (redline) feature and submitting only
those pages with changes. Submittal of the RFP in its entirety is not recommended.
Other potential Offerors are welcome to submit a proposal, but please understand RFP 15-050
REVISED will not allow for a question/answer period. The questions and Revised answers have been
uploaded in BidSync as part of this Revised RFP.
SUBMISSION OF PROPOSALS
1.
Date and Time
All proposals are to be submitted to CalOptima via BidSync. Proposals received after 2:00
p.m., Pacific Time, Thursday, August 6, 2015 will not be delivered to CalOptima by the
BidSync program and will be considered non-responsive. Instructions for using BidSync can
be found on CalOptima’s website www.caloptima.org.
2.
E.
Acceptance of Proposals
a.
CalOptima reserves the right to accept or reject any and all proposals, or any item or
part thereof, or to waive any informalities or irregularities in proposals.
b.
CalOptima reserves the right to withdraw this RFP at any time without prior notice
and CalOptima makes no representations that any contract will be awarded to any
Offeror responding to this RFP.
c.
CalOptima reserves the right to postpone proposal opening for its own convenience.
PRE-CONTRACTUAL EXPENSES
Pre-contractual expenses are defined as expenses incurred by the Offeror in:
1.
preparing its proposal in response to this RFP;
2.
submitting its proposal to CalOptima;
3.
negotiating with CalOptima any matter related to its proposal; or
4.
any other expenses incurred by the Offeror prior to date of award, if any, of the contract.
CalOptima shall not, in any event, be liable for any pre-contractual expenses incurred by Offeror in
the preparation of its proposal. Offeror shall not include any such expenses as part of its proposal.
F.
JOINT OFFERS
Where two or more Offerors desire to submit a single proposal in response to this RFP, they should
do so on a prime-subcontractor basis rather than as a joint venture. CalOptima intends to contract
with a single firm and not with multiple firms doing business as a joint venture.
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RFP 15-050 REVISED
G.
NON-COLLUSION AFFIDAVIT
As part of their Bid Proposal, Offerors are required to complete and sign the Non-Collusion Affidavit
provided as Attachment D to this RFP. Proposals submitted to CalOptima without a fully executed
copy of the Non-Collusion Affidavit may be considered non-responsive.
H.
TAXES
Offeror’s proposals are subject to sales taxes.
I.
J.
CONTRACT TYPE AND TERM
1.
It is anticipated that the contract resulting from this solicitation, if awarded, will be a firmfixed price contract specifying firm-fixed prices for individual tasks specified in the Scope of
Work, included in this RFP as Section V. While firm-fixed price is the preferred method of
pricing, CalOptima will also consider offers quoted on a cost-plus-fixed-fee or time-andexpense basis, although the latter, in particular, may be subject to a significant deduction of
points in CalOptima’s evaluation of the proposals received.
2.
The initial term of any resulting agreement shall be for a period of three (3) years, with an
anticipated effective date of October 1, 2015 through September 30, 2018, with two, one
year options.
a.
Option year one, if exercised, shall be effective October 1, 2018 through September 30,
2019.
b.
Option year two, if exercised, shall be effective October 1, 2019 through September 30,
2020.
CONTRACT AWARD
Issuance of this RFP and receipt of proposals does not commit CalOptima to award a contract.
CalOptima reserves the right to postpone proposal opening for its own convenience, to accept or
reject any or all proposals received in response to this RFP, to negotiate with other than the selected
Offeror should negotiations with the selected Offeror be terminated, to negotiate with more than one
Offeror simultaneously, or to cancel all or part of this RFP. CalOptima also reserves the right to
apportion the award among two or more Offerors.
K.
WITHDRAWAL OF OFFERS
Offers may be withdrawn only by signature of Offeror, provided the request is received by the person
whose duty it is to open proposals prior to the time fixed for proposal opening. Each proposal opened
will be considered to be a valid offer, and may not be withdrawn for a period of 90 calendar days
following the opening of proposals.
L.
STRATEGIC AND CONTRACT ELEMENTS
1.
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CalOptima’s Basic Philosophy: Contracting for Results
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RFP 15-050 REVISED
CalOptima’s fundamental commitment is to contract for results. CalOptima defines a
successful result as a generation of defined, measurable, and beneficial outcomes that satisfy
the contract requirements and support CalOptima’s mission and objectives. This RFP
describes what is required of the successful Offeror in terms of services, deliverables,
performance measures and outcomes, and unless otherwise noted in the RFP, places the
responsibility for how they are accomplished on the successful Offeror.
2.
Contract Elements
a.
The term “contract” means the contract awarded as a result of this RFP 15-050
REVISED and all exhibits thereto (see RFP Section IV: Proposed CalOptima
Contract). The successful Offeror/s will be required to accept a written contract in
accordance with RFP 15-050 REVISED, including all requirements, conditions and
specifications contained therein. The Proposal, including all attachments and
information on services, and associated pricing, shall be binding and shall be
incorporated into the written contract. At a minimum, the following documents will
be incorporated into the contract:
1)
2)
3)
This RFP 15-050 REVISED and all attachments and exhibits;
any modifications, addendum or amendments issued in conjunction with
this RFP 15-050 REVISED; and
successful Offeror’s Proposal.
Should there be any conflict between the RFP 15-050 REVISED and the contract, the
terms and conditions of the contract shall prevail.
M.
b.
Offerors are responsible for reviewing the Contract (RFP Section IV) and providing
with their submission of their Proposal: 1) a signed copy of the enclosed Contract as
written; or (2) a signed, redlined Contract with proposed changes indicating terms it
would like to negotiate, presented as Proposal Attachment E: Request To Negotiate
Contract Terms. It should be noted that as a public agency, CalOptima is mandated
by various government entities to incorporate many of the terms and conditions
listed within the entities Contract and therefore are unable to modify them in any
way. As such, an Offeror’s proposal with excessive suggested contract language
changes shall be given lower marks and/or rejected during the evaluation process.
c.
CalOptima is permitting each Offeror to identify the terms of the Contract that it
would like to negotiate. In Proposal Attachment E, Offerors must identify the
Current Language, Proposed Language, and Rationale for the Request. Note that any
request to negotiate contract terms without a rationale will not be considered for
negotiation. CalOptima will evaluate all requests and render a decision on each
Contract term identified. CalOptima’s decision that it will not negotiate a specific
contract term is final. To continue in the procurement process, Offerors must
provide their agreement to the terms that CalOptima will not negotiate.
USE OF OFFEROR RESPONSE AND ACCOMPANYING MATERIAL
All materials submitted become the property of CalOptima and will not be returned. If the Offeror
intends to submit confidential or proprietary information as part of the proposal, any limits on the use
or distribution of that material should be clearly delineated in writing. However, CalOptima is a public
agency and therefore subject to the Public Records Act.
CalOptima will use reasonable precautions allowed by law to avoid disclosure of the Offeror
proposal. CalOptima reserves the unrestricted right to copy and disseminate the Offeror proposals
for internal review and for review by external advisors, at CalOptima’s sole discretion.
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N.
EXCESS RE-PROCURMENT LIABILITY
Offeror shall be liable to CalOptima for all expenses incurred by CalOptima in re-procuring elsewhere
the same or similar services offered by Offeror hereunder, should Offeror fail to perform or be
disqualified for failure to meet terms and conditions set forth in any awarded contract. Such reprocurement expense obligation by Offeror shall be limited to the excess over the price specified in
any contract awarded for such services.
O.
PRICE ADJUSTMENTS FOR REGULATORY CHANGES
If price adjustment is indicated, either upward or downward, for changes that are mandatory as a
result of any legislation promulgated which become effective between the date of proposal opening
and the date of service termination, said adjustment shall be negotiated between CalOptima and
Offeror. Such price adjustments shall be audited, where required.
P.
BONDING
CalOptima reserves the right to require the respondent to procure one or more performance, fidelity,
payment or other bond, if, during the term of any resulting contract, CalOptima in its sole discretion
determines that there is a business need for such requirement.
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SECTION II.
PROPOSAL CONTENT AND FORMS
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II - PROPOSAL CONTENT AND FORMS
A.
PROPOSAL FORMAT AND CONTENT
1.
Presentation
Proposals shall be typed and submitted in Word or Excel format via BidSync. Offers should
not include any unnecessarily elaborate or promotional material.
Information shall be presented and submitted through BidSync in the order in which
it is requested. Submissions should be submitted in folders or a zipped file structure where
the root file is entitled “Proposal Response.” Files within the folders should be individual
documents, appropriately titled as to their content and in the order in which it is
requested.
Please prepare the RFP documentation on 8.5” x 11” size paper, with a minimum font size of
ten (10). CalOptima encourages all Offerors to try and limit the length of its proposal to 50
pages, and submit a maximum of two documents in the BidSync system. If your proposal
exceeds the limit, only include information specific to this RFP.
2.
Letter of Transmittal
A Letter of Transmittal shall be included with the proposal, addressed to Kathy Hoppe, and
must, at a minimum, contain the following:
3.
a.
identification of Offeror, including name, address, e-mail address and telephone
number;
b.
proposed working relationship between Offeror and subcontractors, and if not
applicable, indicate so;
c.
acknowledgment of receipt of all RFP addenda, if any;
d.
name, title, e-mail address and telephone number of contact person during the
period of proposal evaluation;
e.
a statement to the effect that the proposal shall remain valid for a period of not less
than 90 days from the date of submittal; and
f.
signature of a person authorized to bind Offeror to the terms of the proposal.
Technical Proposal
a.
Qualifications, Related Experience and References of Offeror
This section of the proposal should establish the ability of Offeror to satisfactorily
perform the required work by reasons of: experience in performing work of a
similar nature; demonstrated competence in the services to be provided; strength
and stability of the firm; staffing capability; work load; record of meeting schedules
on similar projects; and supportive client reference.
Offeror shall:
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1) provide a brief profile of the firm, including the types of services offered; the
year founded; form of the organization (corporation, partnership, sole
proprietorship); number, size and location of offices; number of employees;
2) provide evidence of financial stability sufficient to demonstrate reasonable
stability and solvency appropriate to the requirements of this procurement.
Respondents must submit a current financial statement plus two (2) years of
audited financial reports including all supplements, management discussion
and analysis, and actuarial options. At a minimum, such financial statements
and reports shall include: balance sheet; statement of income and expense;
statement of changes in financial position; cash flows; and capital expenditures.
If the respondent is a corporation that is required to report to the Securities and
Exchange Commission, it must submit its two most recent SEC Forms 10K,
Annual Reports. If any change in ownership is anticipated during the twelve
(12) months following the proposal due date, the respondent must describe the
circumstances of such change and indicate when the change is likely to occur;
identify any conditions (e.g., bankruptcy, pending litigation, planned office
closures, impending merger) that may impede Offeror’s ability to complete the
project;
3) describe the firm’s experience in performing work of a similar nature to that
solicited in this RFP, specifically addressing any experience working with MediCal/Medicaid programs; and highlight the participation in such work by the key
personnel proposed for assignment to this project. The respondent must
explain whether it performed the work as a prime contractor or subcontractor.
If the respondent performed the work as a subcontractor, the respondent must
describe the scope of subcontracted activities, and include the prime contractor
as one of the required references;
4) if the respondent proposes to use subcontractor(s), it must describe any
existing or ongoing relationships with the subcontractor(s); including project
descriptions and the portions(s) of this RFP intended to be subcontracted;
5) identify subcontractors by company name, address, contact person, telephone
number and project function and describe Offeror’s experience working with
each subcontractor; and
6) provide, at a minimum, three (3) references for the projects cited as related
experience; references shall include the name, title, email address, address and
telephone number of the person(s) at the client organization who is most
knowledgeable about the work performed. Offeror may also supply references
for other work not cited in this section as related experience.
b.
Proposed Staffing and Project Organization
This section of the proposal should establish the qualifications of the proposed
project staff.
Offeror shall:
1) provide education, experience and applicable professional credentials of project
staff;
2) furnish brief resumes (not more than two [2] pages each) for the proposed
Project Manager and other key personnel;
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3) indicate adequacy of labor resources utilizing a table projecting the labor-hour
allocation to the project by individual task;
4) identify key personnel proposed to perform the work in the specified tasks and
include major areas of subcontract work;
5) include a project organization chart which clearly delineates
communication/reporting relationships among the project staff; and
6) include a statement that key personnel will be available to the extent proposed
for the duration of the project, acknowledging that no person designated as
“key” to the project shall be removed or replaced without the prior written
concurrence of CalOptima.
c.
Work Plan and Price Schedule
Offeror shall provide a narrative which addresses the Scope of Work and shows
Offerors understanding of CalOptima’s needs and requirements.
Offeror shall:
1) describe the approach to completing the tasks specified in the Scope of Work;
and
2) outline sequentially the activities that would be undertaken in completing the
tasks; specify by name and job description, the person your firm would assign to
perform said task; the fixed rate for services performed; and include a schedule
for completing the tasks in terms of elapsed weeks from the commencement
date.
Offeror may also propose enhancement or procedural or technical innovations to
the Scope of Work which do not materially deviate from the objectives or required
content of the project.
d.
Exceptions/Deviations
CalOptima requires each Offeror to state any exceptions to or deviations from the
requirements of this RFP, segregating “technical” exceptions from “contractual”
exceptions. Where Offeror wishes to propose alternative approaches to meeting
CalOptima’s technical requirements, these should be thoroughly explained.
4.
Appendices
Information considered by Offeror to be pertinent to this project which has not been
specifically solicited in any of the aforementioned sections may be placed in a separate
appendix section. Offerors are cautioned, however, that this does not constitute an invitation
to submit large amounts of extraneous materials; appendices should be relevant and brief.
B.
COST AND PRICING
1.
Section II
7/23/2015 8:45 AM
CalOptima’s intention is to award a firm-fixed price contract. Utilizing the format and
information requested in the 2nd bullet of paragraph A.3.c of this Section II, Offeror
shall create a Price Schedule and provide any narrative necessary to explain or qualify the
prices quoted. All costs associated with implementation shall be broken down by resource
requirements and milestones. Prices quoted shall include direct costs, indirect costs, and
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profits. If the pricing method differs from firm-fixed price, attach an explanation as to why
an alternate pricing method is proposed.
2.
C.
Offeror shall identify and list any other additional or incidental costs which will be required
by your firm in order to meet the requirements of the Scope of Work and Price Schedule.
Successful Offeror shall not be allowed to invoice CalOptima for any pricing not listed within
the Price Schedule throughout the duration of any resulting contract.
PAYMENT TERMS
Unless discount payment terms are offered, payment terms shall be “Net 30 Days.” Discount
payment terms of less than 10 days will not be considered in making award. Payment due dates,
including discount period, will be computed from the date of CalOptima acceptance of the required
goods and/or services or of a correct and complete invoice, whichever is later, to the date
CalOptima’s check is mailed. Any discounts taken will be taken on full amount of invoice, unless
other charges are itemized and discount thereon is disallowed.
Section II
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SECTION III.
EVALUATION AND AWARD
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III.
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Evaluation of the proposals shall be generally based upon the experience in the market and capabilities of the
Offeror to effectively complete the project requirements; financial stability; reasonableness of price; and
completeness of the proposal response and the requested data.
All proposals received as specified will be evaluated by CalOptima staff in accordance with the above criteria
and additional sub-criteria that may be considered as relevant or pertinent by the evaluators. During the
evaluation period, CalOptima may require interviews and an on-site visit and/or tour of the Offeror’s place of
business. Offerors should be aware, however, that award may be made without Offeror visits, interviews, or
further discussions.
In accordance with CalOptima’s Purchasing Policy, CalOptima staff will select the Offeror best meeting the
evaluation criteria or submit a recommendation to CalOptima’s Board of Directors, for consideration and
selection.
CalOptima reserves the right to withdraw this RFP at any time without prior notice and, furthermore, makes
no representations that any contract will be awarded to any Offerors responding to this RFP. CalOptima
expressly reserves the right to postpone proposal opening for its own convenience, to waive any informality
or irregularity in the proposals received, and to reject any and all proposals responding to this RFP without
indicating any reasons for such rejection.
CalOptima also reserves the right to award its total requirement among two or more Offerors as CalOptima
may deem to be in its best interests. In addition, negotiations may or may not be conducted with Offerors;
therefore, the proposal submitted should contain the Offerors most favorable terms and conditions, since the
selection and award may be made without discussion with any Offeror.
Offerors who submit a proposal in response to this RFP shall be notified in writing regarding whether their
firm was awarded the contract. Such notification shall be made within a reasonable time after the date the
contract is awarded.
Section III
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SECTION IV.
SAMPLE CONTRACT
15-050
Agreement3.pdf
Section IV
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SAMPLE CONTRACT
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SECTION V.
SCOPE OF WORK
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RFP 15-050 REVISED
V. SCOPE OF WORK
A.
BACKGROUND
CalOptima is currently using a clinical editing software that operates in batch mode. On a nightly
basis, claim data files are feed to an external vendor who then runs them through a series of data
scrubbing edits. Data is fed back to CalOptima and worked on a daily basis to adjust claims.
“Worked” shall be described as “the file is returned and the Vendors recommendations are reviewed
annually by a CalOptima Claims analyst who then determines whether or not to accept or reject the
vendors recommendation for savings.” This process has proven labor intensive with the growth of
CalOptima, and nightly batch windows have become limited. With the successful Offieror’s solution,
CalOptima will have a software solution that can apply data scrubbing edits in an automated fashion.
B.
OBJECTIVE
The purpose of this RFP is to identify and contract with a vendor by September 30, 2015 to implement clinical
edits within CalOptima’s CORE system (Facets). CalOptima currently uses Verisk, and has since 2008 for daily
claims review. CalOptima would like to contract with a vendor that offers real-time automated clinical edits
to include prepayment NCCI edits (National Correct Coding Initiative) which can be executed as claims are
being processed. This means the product must interact with CalOptima’s Facets CORE application during
claims processing as opposed to the way it is executed today via batch processing. CalOptima also requires
reporting capabilities from this product.
C.
SCOPE OF WORK
1.
Licensor shall implement a clinical editing software solution to interact with CalOptima’s
CORE system (Facets) to apply clinical edits to claims that are either being loaded via batch
processes or being adjudicated manually.
2.
Selected solution must interact successfully with multiple other claims payment extensions
already in place. For example, Burgess Auto-Pricer, Sanctions extension, and Facets
NetworX Pricer.
3.
Selected solution must perform clinical edits in a timely manner to ensure there is no impact
to end users. For a per claim perspective, a solution that returns clinical edit results in less
than 10 seconds per claim is acceptable.
4.
As part of your organization’s proposal response, please answer all questions listed below.
a.
How many years has your organization been providing claims management/clinical
editing solutions? Describe how your solution differentiates itself from that of other
editing solution vendors.
b.
Describe your organization’s strategy and direction for serving the health insurance
payer market.
c.
Is your organization able to respond to quickly changing industry demands? If so,
how?
d.
Indicate how many covered lives are currently impacted by your organization’s
solutions.
Section V – Scope of Work
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D.
E.
IMPLEMENTATION REQUIREMENTS
1.
CalOptima’s expectation is the clinical editing tool must be implemented by December 31,
2015, if not sooner. As part of your proposal, provide an implementation project plan to
include timeline, resource requirements, and milestones.
2.
Licensor shall provide a project lead along with dedicated analyst and programmer
resources to work with CalOptima resources during development, implementation, and postimplementation phases. As part of your proposal, identify the vendors typical resource plan
for a project of this size which includes Licensor and client resource requirements, roles,
deliverables and milestones for a typical implementation.
3.
Licensor shall provide post implementation project support for a three month warranty
period which shall then turn into technical support.
4.
Describe in detail, your organization’s implementation documentation and tools that are
used during the course of the project.
5.
Licensor shall provide CalOptima with consulting services to assist with implementation.
6.
Describe in detail, the type and amount of CalOptima resources that will be required during
the different phases of implementation.
7.
During the last 60 days prior to project implementation, the vendor shall lead knowledge
transfer efforts to CalOptima resources with supporting documentation. Describe in detail,
the supporting documentation your organization will provide CalOptima during the
knowledge transfer process.
8.
During the course of the project, Licensor shall provide weekly status reports. This report
shall include progress, issues log, milestones with completion status, etc.
9.
The Licensor’s project team shall provide training materials and web-based training for
CalOptima resources. Describe in detail the types of training materials it shall provide and
the quantity of web-based training hours it will provide to CalOptima.
10.
Licensor shall provide CalOptima with end user documentation in the form of user guides.
11.
Licensor shall provide on-site training throughout the implementation phases, as well as adhoc training should CalOptima desire, throughout the duration of any resulting contract.
12.
As part of your proposal, provide any additional information your organization believes
would be beneficial to CalOptima in the development of an implementation plan.
13.
As part of your organization’s proposal response, please answer all questions listed below.
a.
Describe in detail how your organization’s approach will benefit CalOptima?
b.
How long is a typical implementation for a client CalOptima’s size?
FUNCTIONAL REQUIREMENTS
1.
Clinical Editing Capabilities
a.
Describe in detail, the clinical organization responsible for the development and
support of your organizations clinical edits.
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b.
Define in detail, the contents and sources of your organizations clinical edits.
c.
Licensor shall follow the most recent version of the National Correct Coding
Initiative (CCI) rules.
d.
Licensor shall have the most updated and current CMS rules imbedded in its
product throughout the duration of any resulting contract.
e.
Licensor shall have the most updated and current DHCS specific edits imbedded in
product throughout the duration of any resulting contract.
f.
Licensor shall describe how frequency rules are managed in the solution as well as
identify those that are hard-coded.
g.
Licensor shall describe in detail, the solutions duplication rules and how they are
managed.
h.
Licensor’s solution shall have age/gender edits that drive from diagnosis and
procedure codes.
i.
Licensor shall describe edits such as assistant surgeon, co-surgeon, and team
surgeon edits.
j.
Licensor shall explain the functionality for cosmetic procedures and procedures
typically looked at as investigational.
k.
Licensor shall explain the ability to edit HCPC Level II codes.
l.
Licensor shall explain edits to bundle lab procedures into the appropriate organ
disease panel when they are billed separately.
m.
Licensor shall explain the logic and editing functionality to indicate which modifiers
are appropriate on specific procedure codes as defined by CMS and DHCS billing and
payment guidelines.
n.
Licensor shall explain additional modifier logic and limitations when multiple
modifiers are used to drive payment.
o.
Licensor shall explain edits that could be customized by ranges of codes. (e.g.
Anesthesia, radiology, and lab).
p.
Licensor shall supply CalOptima with documentation and tools used to support the
edits in place.
q.
Licensor shall discuss the options where the edits can be applied in the claims
processing workflow.
r.
Licensor shall explain how the organization determines the best place within the
adjudication process to apply edits in the claims process taking into consideration
existing extensions.
s.
Licensor shall explain whether or not the editing rules applied by the solution are
referenced anywhere as well as discuss the source/rationale for each edit applied to
a claim.
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2.
3.
t.
Licensor shall explain how the product functionality or customization capabilities
ensure claims payments align with our medical and payment policies.
u.
Licensor shall explain whether or not the product allows for auditing claims
submitted by same providers, by specialty and/or by lines of business, as well as
unique editing rules to be applied to each of these groups.
Flexibility
a.
Licensor’s solution shall support various payment models in addition to fee for
service (FFS), e.g., episodes of care/bundled payments, value-based reimbursement
b.
Licensor’s solution shall have capabilities to modify the existing edits in CalOptima’s
system based upon the needs of CalOptima. Modifications would include edits at the
provider, group, or specialty, line of business, service, etc. level.
c.
Licensor’s solution shall have functionality to turn on/off individual edits for
individual group or line of business.
d.
As part of your proposal response, Licensor shall describe the customization
process that a health plan/CalOptima will follow if your solution is chosen as the
successful Offeror. This must include a thorough workflow diagram describing the
Licensor’s process.
e.
Licensor’s solution shall process ICD-9 in their native form with dates of service
after 10-1-15 (e.g. maintain IDC-9 capabilities beyond the compliance date; avoid
any transformation of ICD-9 into ICD-10).
f.
Licensor’s solution shall allow configuration of custom rules that set procedure
limitations and frequency by units, quantity, time, number of visits and/or date
ranges.
g.
Licensor’s solution shall allow users to define editing criteria by the presence or
absence of specific procedure codes, diagnosis codes or modifiers.
h.
As part of its proposal, Licensor shall describe in detail the products customization
utilities. CalOptima is interested in the ability to create custom rules or user defined
edits as well as custom internal and/or external messaging for customized rules.
i.
As part of Licensor’s proposal response, please answer the following questions.
1)
How many data elements can be included within a customized rule/edit?
2)
Can unique rules/edits be developed for a specific plan, line of business?
3)
Can rules/edits by place of service, provider groups, employer groups, etc.
be created?
Transparency
As part of its proposal, Licensor shall describe in detail, if its solution offers a transparency /
disclosure tool for external providers to access the clinical rationale supporting Licensor’s
edits.
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4.
5.
6.
F.
History Processing
a.
As part of its proposal, Licensor shall describe in detail, the storage of historical
claims along with where the claims are stored (claims system or other platform).
b.
The Licensor’s solution shall have the ability to process historical claims.
c.
The Licensor’s solution shall have the ability to capture historical timeframes for
claims, i.e. 90 days, 1 year, 3 years.
User Interface and Reporting
a.
As part of its proposal response, Licensor shall describe their user interface in
detail.
b.
As part of its proposal response, Licensor shall describe, in detail, the standard
reports for the executive and operational level available from its solution, including
usefulness and frequency.
c.
As part of its proposal response, Licensor shall describe in detail, their reporting
capabilities.
New Releases and Clinical Updates
a.
Licensor shall publish their edit release / update schedule and process. CalOptima
must know the time between new code releases and the update of edits being
released to the health plan/CalOptima.
b.
As part of its proposal response, Licensor shall describe the process of applying
code updates and maintenance of codes along with turnaround times CalOptima
should expect for production downtime.
c.
As part of its proposal response, Licensor shall provide CalOptima with the
frequency of published documentation releases for edit updates.
d.
As part of its proposal response, Licensor shall provide their company holiday
schedule.
e.
As part of its proposal response, Licensor shall explain their update / upgrade
process and the level of effort required from CalOptima. As well, vendor shall
describe in detail, the documentation and tools used for upgrades of clinical editing
content.
TECHNICAL REQUIREMENTS
1.
Functionality
a.
The Licensor’s solution shall process clinical edits against claims in real-time
whether the claims are processed manually or via batch mode.
b.
The Licensor’s solution shall have scalability to handle large volumes of claims
required by CalOptima. CalOptima currently processes 7k – 15k claims on a daily
basis.
c.
As part of its proposal response, Licensor shall provide its standard benchmarking
technique currently in place for tracking processing response times.
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2.
3.
4.
d.
As part of its proposal response, Licensor shall provide an overview of the systems
architecture for its solution.
e.
CalOptima currently has its claims processing running in an automated fashion with
an EDI portal (dashboard) that tracks files, counts, errors, etc. Licensor shall be able
to integrate its solution to CalOptima’s automated solution or be able to work in
sync with the solution.
Specifications
a.
As part of its proposal response, Licensor shall provide a list of any required or
suggested third-party software specifications and requirements.
b.
As part of its proposal response, Licensor shall describe the supported interfaces,
transmission standards, and file protocols needed to support the solution.
c.
As part of its proposal response, Licensor shall describe the architectural
infrastructure.
d.
As part of its proposal response, Licensor shall describe the method for transmitting
/ receiving claims data.
Scalability
a.
As part of its proposal response, Licensor shall describe system capacity limitations
regarding simultaneous user access or record or interface processing.
b.
As part of its proposal response, Licensor shall describe how their solution will help
CalOptima address future growth.
Security
a.
As part of its proposal response, Licensor shall describe the security features of the
solution, including, but not limited to:
1)
2)
3)
4)
5)
6)
7)
5.
b.
As part of its proposal response, Licensor shall describe the process required for
setup and administration of user groups, access controls, and users.
c.
Complete RFP Attachment A: Security Questionnaire to describe your organizations
standards for security, privacy, compliance and risk management and adherence to
industry and government best practices.
d.
Indicate the location and capacity of your data center(s). Describe your information
systems disaster and recovery plans. Identify applicable locations
Auditing Trail Functionality
a.
Licensor’s solution shall provide an audit trail for all claims editing transactions.
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the security model
access control features
ID/password rules
encryption
integration ability with other authorization/authentication systems
security administration tools
role-based security rules
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b.
G.
Licensor’s solution shall provide system customization activity.
SERVICE AND SUPPORT
1.
As part of its proposal response, Licensor shall describe its approach to ongoing maintenance
and support.
2.
As part of its proposal response, Licensor shall indicate who CalOptima’s principal point of
contact will be post-implementation.
3.
As part of its proposal response, Licensor shall describe in detail, product technical support and
include any associated fees, if applicable, in its price schedule.
4.
As part of its proposal response, Licensor shall describe the hours and response times for
technical support.
5.
As part of its proposal response, Licensor shall provide system down-time analysis for the past 2
years.
6.
As part of its proposal response, Licensor shall provide the metrics used by your company to
measure customer satisfaction with your support and explain how this information is used.
7.
As part of its proposal response, Licensor shall describe how it will provide information to
CalOptima regarding any opportunities for users (clients) to meet and share information (e.g.
user group or user conference).
8.
As part of its proposal response, Licensor shall describe opportunities for customers to provide
input to product enhancements or future product direction.
9.
As part of its proposal response, Licensor shall describe their web-based tools for customer
support, if any.
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Attachment B
SECURITY QUESTIONNAIRE
Offeror is required to certify that it (and any proposed subcontractors) comply with the following security
provisions, as required in RFP 15-050 REVISED Section V.E.2.c. Offeror must complete the following
questionnaire and explain how you propose to meet any exceptions.
1.
2.
3.
Information Security Program, Policy & Procedures
a.
Do you have documented information security policies and procedures? If so list the titles of each
policy.
b.
Does your organization perform background checks to examine and access an employees or
contractor’s work and criminal history?
Personnel Security
a.
Has your organization formally appointed a central point of contact for security coordination? If so,
whom, and what is their position within the organization?
b.
Do you work with third parties, such as IT service providers that have access to or store your
sensitive information?
c.
In the event of a security incident with one of your third-party vendors, what is the policy for alert
notifications, timeline for resolution, etc? If such a process exists, provide the document as part of
your response as Proposal Exhibit: Third-party Security Event Notices.
Network Security
a.
Describe your network configuration. Has your IT vendor provided information regarding how
your sensitive information systems are protected?
b.
Are systems and networks that host, process and or transfer sensitive information “protected”
(isolated or separated) from other systems and/or networks?
c.
Are internal and external networks separated by firewalls with access policies and rules?
d.
Is there a standard approach for protecting network devices to prevent unauthorized
access/network related attacks and data-theft?
e.
Is sensitive information transferred to external recipients? If so, what controls are in place to
protect sensitive information when transferred (e.g. with encryption?)
f.
Is sensitive information encrypted in transit? If so, please explain.
g.
Does your company have a Vulnerability Management program? If so, how often are Vulnerability
Assessments performed?
h.
What is the remediation process for vulnerabilities that are discovered?
i.
Are third party connections to your network monitored and reviewed to confirm authorized access
and appropriate usage?
j.
What network security tools do you have in place? (i.e., DLP, IPS/IDS, Advanced Malware Detection,
Web Content Filtering, etc.).
Attachment B
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Attachment B
k.
4.
Describe your methodology for tuning your security tools (i.e., DLP, IPS, Advanced Malware
Detection, Web Content Filtering, etc.)
Operations Management
a.
Has antivirus software been deployed and installed on your computers and supporting systems
(e.g., desktops, servers and gateways?)
b.
Are systems and networks monitored for security events? If so, describe monitoring in detail.
c.
Do procedures exist to protect documents, computer media (e.g., tapes, disks, CD-ROMs, etc.) from
unauthorized disclosure, modification, removal, and destruction? Is sensitive data encrypted when
stored on laptop, desktop and server hard drives, flash drives, backup tapes, etc.?
d.
Which company manages off site backup tapes (if applicable)?
e.
Are there security procedures for the decommissioning (replacement) of IT equipment and IT
storage devices which contain or process sensitive information? If so, please describe.
f.
Are development, test and production environments separated from operational IT environments
to protect production (actively used) applications from inadvertent changes or disruption?
g.
Are duties separated, where appropriate, to reduce the opportunity for unauthorized modification,
unintentional modification or misuse of the organization’s IT assets?
h.
Do formal change management procedures exist for networks, systems, desktops, software
releases, deployments, and software vulnerability (e.g., Virus or Spyware) patching activities?
Attachment B
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Attachment B
ADDITIONAL INFORMATION
As part of its proposal response, Licensor shall provide the following information regarding its proposed
solution.
1.
What other health care reform models does your solution support? Please describe.
2.
Describe all service level agreements and performance metrics for your services.
3.
Describe any other CalOptima technical requirements related to implementing your services.
4.
Describe how your proposed system meets HIPAA security and privacy requirements as it pertains to
website access and servers, data storage and transmission of PHI, and use of remote devices, if
applicable.
5.
Does your product support the ability to do forensic review? If so, please describe.
6.
What categories of data will CalOptima be required to supply? What categories of data will you
provide back to CalOptima? Describe any data interface requirements related to implementing your
services.
Attachment B
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Attachment C
ACKNOWLEDGEMENT
In signing this proposal, Offeror acknowledges receipt of 15-050 REVISED and the following addenda, if any:
Addendum no.
,
Received on:
Addendum no.
,
Received on:
Addendum no.
,
Received on:
I acknowledge receipt of 15-050 REVISED and addenda No.(s) _________________________
I hereby certify on behalf of ___________________________ that the contents of this proposal are, to the best
of my ability, completely in compliance with all requirements of the RFP, and the terms and
conditions of the Sample Contract, without exceptions, other than those expressly listed and
explained in this proposal. This proposal is an irrevocable offer, which shall remain in full force and
effect for 90 days after the proposal due date.
Company Name:
Address:
Telephone Number:
Signature Of Person Authorized To
Bind Offeror:
Signatory’s Name And Title:
Date Signed:
Attachment C
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Attachment D
NON-COLLUSION AFFIDAVIT
STATE OF CALIFORNIA
COUNTY OF
The undersigned, being first duly sworn, deposes and says as follows:
1.
This Affidavit is executed by the undersigned
,
(Typed or Printed Name)
whose title is
(Title)
, on behalf of
, the party
(Bidder Name)
submitting the foregoing proposal (the “Bidder”) in response to 15-050 REVISED (“Proposal”).
2. The Proposal is not made in the interest of, or on behalf of, any undisclosed person, partnership,
company, association, organization, or corporation.
3.
The Proposal is genuine and not collusive or sham.
4. The Bidder has not directly or indirectly induced or solicited any other bidder to put in a false or sham
bid, and has not directly or indirectly colluded, conspired, connived, or agreed with any other bidder or
anyone else to put in a sham bid, or to refrain from bidding.
5. The Bidder has not in any manner, directly or indirectly, sought by agreement, communication, or
conference with anyone to fix the bid price, or that of any other bidder, or to fix any overhead, profit or cost
element of the bid price or that of any other bidder, or to secure any advantage against the public body
awarding the contract or of anyone interested in the proposed contract.
6.
All statements contained in the Proposal and related documents are true.
7. The Bidder has not, directly or indirectly, submitted the bid price or any breakdown thereof, or the
contents thereof, or divulged information or data relative thereto, or paid, and will not pay, any fee to any
person, corporation, partnership, company, association, organization, bid depository, or to any member or
agent thereof to effectuate a collusive or sham bid.
Executed this
day of
, 2015 at
.
(City, County and State)
I declare under penalty of perjury under the laws of the State of California that the foregoing is true and
correct.
(Signature)
(Address)
(Name Printed or Typed)
(City, County and State)
(Area Code and Telephone Number)
Attachment D
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ATTACHMENT E
REQUEST TO NEGOTIATE CONTRACT TERMS
(Must be included as Attachment E to Offeror’s Proposal if Offeror has redlined proposed Contract.)
Use additional pages as needed.
Contract Page/Section Number: _____________________
Current Language: _______________________________________________________
Proposed Language Change: _______________________________________________
Rationale for the Request: ____________________________________________________
CalOptima Decision: ___________________________________
Contract Page/Section Number: ___________________________
Current Language: _______________________________________________________
Proposed Language Change: _______________________________________________
Rationale for the Request: ______________________________________________________
CalOptima Decision: _____________________________________
Signature of Offeror Representative: _______________________________________
Printed Representative Name/Title: _______________________________________
Company: ___________________________________________________________
Date: ________________
Attachment E
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RFP 15-050 REVISED
QUESTIONS AND REVISED ANSWERS
QUESTION 1
Refer to Section V.E.1.g. of the RFP - Licensor shall describe in detail, the solutions duplication rules and
how they are managed.
Question: Can CalOptima provide specific examples of the duplication rules they are looking for the
bidders to describe?
Answer: Clarification - Describe the proposed solution’s process for identification of duplicate services
billed on the same claim.
QUESTION 2
Refer to Section V.E.1.n - Licensor shall explain additional modifier logic and limitations when multiple
modifiers are used to drive payment.
Question: Can CalOptima provide specific examples of the additional modifier logic and limitations they are
looking for the bidders to describe?
Answer: Example - Surgery claim is billed with the following modifiers:
51 – Multiple Surgery
50 – Bilateral Procedure
62 – Two Surgeons.
Define how the proposed solution would determine appropriate level of payment.
QUESTION 3
Refer to Section V.E.1.u. - Licensor shall explain whether or not the product allows for auditing claims
submitted by same providers, by specialty and/or by lines of business, as well as unique editing rules to be
applied to each of these groups.
Question: Can CalOptima provide examples of the desired auditing and editing functionality for these
groups?
Answer: Clarification - Does the proposed solution editing end at the claim level, or is there an option to
review billing patterns by provider type, geographical location, line of business, etc.?
QUESTION 4
Refer to Section V.E.2.e - Licensor’s solution shall process ICD-9 in their native form with dates of service
after 10-1-15 (e.g. maintain IDC-9 capabilities beyond the compliance date; avoid any transformation of
ICD-9 into ICD-10).
Question: Can CalOptima provide specific guidance on the scenarios and/or lines of business that require
ICD-9 coding for claims with dates of service after 10-1-2015?
Answer: Clarification - ICD-9 codes may be submitted for services with DOS after 10-1-2015 if such
services were authorized prior to 10 -1-2015 and the authorization is specific to the ICD-9 code. Describe
1
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CalOptima
Bid 15-050-Revised
RFP 15-050 REVISED
the proposed solutions process for accurately reviewing these claims (i.e. internal ICD9 – ICD-10 crosswalk,
etc).
QUESTION 5
Refer to Section V. F. 2. c. As part of its proposal response, Licensor shall describe the architectural
infrastructure.
Question: Can CalOptima provide additional guidance on the aspects of the infrastructure they want
described?
Answer: CalOptima would like the vendor to describe the architectural infrastructure of any system at
vendors’ location that is used to support the processing of clients data. A flow chart or Visio with a high
level explanation should be sufficient for this request.
QUESTION 6
Refer to Section V.F. 5. b - Licensor’s solution shall provide system customization activity.
Question: Can CalOptima provide examples of system customization activity they are looking to track
within the Auditing Trail Functionality?
Answer: Clarification – Does the proposed solution offer the ability to customize audit trail functionality by
LOB, payment type, Override Type, Impacted Dollar Threshold, etc.
QUESTION 7
Refer to Attachment B, 3.i. Are third party connections to your network monitored and reviewed to confirm
authorized access and appropriate usage?
Question: Does your definition of "third party access" include our users? Can you clarify your definition of
third party connections?
Answer: Third party users would include any other hosted software / applications that are connected
through your network to support your processes. As well, CalOptima would like to know the authorization
process used by each connection string for client processes.
QUESTION 8
Question: How many covered lives are you processing on which you are paying professional claims?
12
Month
Averag
e
MediCal
Medica
re
(Duals)
PACE
Professio
nal Claims
Paid w/o
Edits
Member
Count for
Profession
al Claims
Paid
Institutio
nal
Claims
Processe
d
Institutio
nal
Claims
Processed
w/ Edits
Institutio
nal
Claims
Processed
w/o Edits
Member
Count for
Institution
al Claims
Paid
Total
Membe
rs
Professio
nal Claims
Processed
Professio
nal Claims
Paid with
Edits
698,490
247,110
144,419
102,690
35,616
70,991
33,824
37,167
14,049
13,580
4,035
2,008
2,026
594
2,406
2,005
402
597
71
296
252
44
9
41
33
8
7
2
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CalOptima
Bid 15-050-Revised
RFP 15-050 REVISED
Total
12
Month
s
MediCal
Medica
re
(Duals)
PACE
Professio
nal Claims
Processed
Professio
nal Claims
Paid with
Edits
Professio
nal Claims
Paid w/o
Edits
Member
Months
for
Profession
al Claims
Paid
2,965,315
1,733,031
1,232,284
427,389
851,891
407,404
444,487
168,590
162,962
48,415
24,101
24,314
7,127
28,876
24,057
4,819
7,164
851
3,550
3,024
526
107
496
401
95
88
Total
Membe
r
Months
8,381,8
75
Membership
Forecast
1/1/20
16
Type
6/1/201
6
801,259
MCAL
830,435
28,782
OCC
39,129
2,000
OC
2,000
150
PACE
Institutio
nal
Claims
Processe
d
Institutio
nal
Claims
Institutio
nal
Claims
Processed
w/ Edits
Processed
w/o Edits
Member
Months
for
Institution
al Claims
Paid
200
QUESTION 9
Question: Do you apply the same payment policies for all your lines of business and all providers or do you
have separate payment policies for each line of business and provider?
Answer: Payment policies are designed separately for each line of business.
QUESTION 10
Refer to Section V.F. 1.b Technical Requirements.
Question: How many of the 7k-15k claims per day are professional claims?
Answer:
70 – 80%
QUESTION 11
Question: Is CalOptima looking to implement a customer-hosted solution or a vendor-hosted solution.
Answer: CalOptima is leaning towards a vendor hosted solution but would consider a customer-hosted
solution. Please submit an installation proposal to fit CalOptima’s needs based upon your
understanding of the requirements. If customer- or vendor-hosted are both options, please be sure to
submit information and cost regarding both alternatives.
QUESTION 12
Question: Our solutions use an Oracle database. We provide our solutions with two hosting options –
customer hosted, in which CalOptima has the responsibility to install and run the software, and Vendor
hosted, where we provide the solution for you. Does CalOptima have in-house support for Oracle databases
3
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CalOptima
Bid 15-050-Revised
RFP 15-050 REVISED
and if not, would you have a problem using Oracle database software in your environment?
Answer: CalOptima does not currently have the infrastructure/resources to support a customer-installed
Oracle database and architecture.
QUESTION 13
Refer to Section V.D.12 Implementation :
Question: Is CalOptima asking Vendor to provide guidance to CalOptima on steps they can take to prepare
for a successful implementation of the solution?
Answer: CalOptima is asking the Vendor for best practices and examples of previous successful
implementations of the vendor solution.
QUESTION 14
Refer to Section II . A . 1. Presentation.
Question: Can CalOptima please clarify the way in which the documents should be packaged for
submission?
In a reference within the Presentation item, we are asked to submit responses in “folders or a zipped file
structure,” where “… files within the folders should be individual documents, appropriately titled as to their
content…” In a reference in the final paragraph of this item, we are asked to “…submit a maximum of two
documents in the BidSync system.”
Instead of “documents,” does CalOptima mean that there is a preference for a maximum of two “folders” in
the system, as the RFP seems to require more than two response documents in total?
Answer: Disregard maximum of two documents. Please submit documents as follows:
Information shall be presented and submitted through BidSync in the order in which it is requested.
Submissions should be submitted in folders or a zipped file structure where the root file is entitled
“Proposal Response.” Files within the folders should be individual documents, appropriately titled as to
their content and in the order in which it is requested.
Please prepare the RFP documentation on 8.5” x 11” size paper, with a minimum font size of ten (10). Only
include information specific to this RFP.
QUESTION 15
Question: Can CalOptima provide additional information regarding the format(s) of claims/encounter(s)
data currently being received from training partners?
Answer: CalOptima receives claims in an 837 Professional or Institutional format. We do have one trading
partner that submits via a proprietary text format however the file contains required data to support claims
adjudication in our Core system
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CalOptima
Bid 15-050-Revised
RFP 15-050 REVISED
QUESTION 16
Refer to Section V.D.9 Implementation Requirements:
Question: Can CalOptima provide additional information about CalOptima’s organization structure
(including the number / type of staff by area) that can be used to scope the overall training approach and
level of effort?
Answer: Training will be required for Claims and Information Services staff of approximately 70.
Approximately 50 of these are claims examiners, the remainder includes Claims leadership and
Information Services staff and leadership. Please propose the recommended training approach and
level of effort based on these counts.
QUESTION 17
Refer to Section V.E.1.h Functional Requirements:
Question: Can CalOptima provide an example of the "age/gender edits that drive from diagnosis and
procedure codes"?
Answer: Example:
Diagnosis Code: 01640, Invalid Gender: F, ICD-9 Code Description: Tuberculosis of epididymis, confirmation
unspecified;
Diagnosis Code: 01641, Invalid Gender: F, ICD-9 Code Description: Tuberculosis of epididymis,
bacteriological or histological examination not done
Diagnosis Code: 01642, Invalid Gender: F, ICD-9 Code Description: Tuberculosis of epididymis,
bacteriological or histological examination unknown (at present)
Diagnosis Code: 01643, Invalid Gender: F, ICD-9 Code Description: Tuberculosis of epididymis, tubercle
bacilli found (in sputum) by microscopy
bacilli not found (in sputum) by microscopy, but found by bacterial culture;
bacilli not found by bacteriological examination, but tuberculosis confirmed histologically
QUESTION 18
Refer to Section V.E.1.j. Functional Requirements.
Question: Can CalOptima provide an example of the "cosmetic procedures and procedures typically looked
at as investigational"?
Answer: Clarification Cosmetic Procedures:
5
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Bid 15-050-Revised
RFP 15-050 REVISED
1. Reduction Mammoplasty (CPT 19318). This procedure will be denied when performed for a cosmetic
reason (V50.1).
2. Mastectomy for gynecomastia (19300): If the tissue removed is primarily fatty tissue, the surgery is
classified as cosmetic (V50.1) and will be denied as non-covered.
3. Punch graft hair transplant (CPT 15775-15776) To indicate this procedure is performed for cosmetic
reasons, use (V50.0) hair transplant to receive a non-covered denial.
4. Rhinoplasty (CPT codes 30400-30450) When nasal surgery is performed solely to improve the patient's
appearance in the absence of any signs and/or symptoms of functional abnormalities, it is considered
cosmetic (V50.1) and will be denied as non-covered.
5. Excision, excessive skin and subcutaneous tissue (including lipectomy); abdomen (abdominoplasty)
(15830) is not covered when performed to improve the patient's appearance (V50.1).
6. Chemical Peel (15788-15793) For cosmetic reasons (V50.1) will be denied as not covered
7. Dermabrasion, segmental, face (15781) performed for a cosmetic reason (V50.1) will be denied as noncovered.
8. Rhytidectomy (15828, 15829) performed for a cosmetic reason (V50.1) will be denied as non covered.
Investigational Procedures:
A medical procedure or device is considered experimental or investigational and a non-covered benefit if
ANY of the following criteria are met:
1. An approval from federal or other governmental body is required and that approval has not been
granted, or does not have unrestricted market approval from the Food and Drug Administration (FDA), or
final approval from any governmental regulatory body for use in treatment of a specified condition is not
granted; or
2. The procedure or device is under investigation in a properly-controlled Phase I-III clinical trial; or
3. There is insufficient or inconclusive medical and scientific evidence to permit evaluation of therapeutic
value and benefit to the member; or
4. There is inconclusive medical and scientific evidence in peer-reviewed medical literature that there is a
beneficial effect on health outcomes; or
5. Evidence suggests the procedure or device under consideration is not as beneficial as any established
alternatives; or
6. Reliable evidence shows that the prevailing opinion among experts regarding the procedure or device
requires further study or clinical trials to determine the safety and efficacy as compared with standard
means of treatment.
Codes:
1. Non-Covered CPT © Codes
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CalOptima
Bid 15-050-Revised
RFP 15-050 REVISED
2. All CPT codes designated as unlisted procedures when billed for experimental and investigational
services.
3. Non-Covered CPT © Category III Codes
4. All Category III codes are temporary codes for emerging technology, services and procedures.
5. Non-Covered HCPCS Level II© Codes
6. All HCPCS Level II Codes designated as unlisted or not otherwise classified.
QUESTION 19
Refer to Section V.E.2.a. (Flexibility):
Question: Are the various payment models, FFS and value-based reimbursement, specific to line of
business partners and the data that is submitted to CalOptima? For example, does a single primary care
provider submit data for both FFS and value-based reimbursement? If they do, do they have different
identifiers? For example the provider would have 1001 as the identifier for their FFS claims and 1002 for
their value-based reimbursement data.
Answer: The payment models associated with each line of business, provider group or specialty type
resides in the core operation system and is not transmitted by the provider on the claim.
QUESTION 20
Refer to Section V.E.4.a History Processing:
Question: Does the statement “the storage of historical claims along with where the claims are stored”
mean that there will be a data conversion effort to convert data from the legacy system into the new
system?
Answer: Clarification - Data storage refers to the ability of the proposed solution to compare the current
claim under review against previously submitted claims and uncover aberrant billing patterns.
QUESTION 21
Refer to Section V.F.1.e Functionality:
Question: Does CalOptima’s “EDI portal (dashboard) that tracks files, counts, errors, etc.” support HTML or
XML?
Answer: CalOptima’s web EDI Portal can support both HTML and XML.
QUESTION 22
Refer to Attachment B Additional Information:
Question: Besides supporting system audits, can CalOptima provide an example of "forensic review"?
7
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CalOptima
Bid 15-050-Revised
RFP 15-050 REVISED
Answer: Clarification - Forensic claims review is the analysis of billing patterns against local or national
norms.
8
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CalOptima
Question and Answers for Bid #15-050-Revised - Clinical Editing Solution - Revised
Bid 15-050-Revised
5
Overall Bid Questions
There are no questions associated with this bid. 6
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Solicitation 15-050-Revised Clinical Editing Solution

Transcription

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