HHS IHS Sources Sought: Purchased/Referred Care Fiscal Intermediary Services

Solicitation 75H70420R00001

The Purchased/Referred Care (PRC) Program is an integral part of the IHS system. The IHS delivers care through direct care services provided in an IHS, Tribal or Urban Indian Health Program (I/T/U) facility and through PRC services delivered by non-IHS providers. The PRC Program allows Federal or Tribal facilities to purchase services from private health care providers in situations where: 1) no IHS or Tribal direct care facility exists; 2) the existing direct care element is incapable of providing required emergency and/or specialty care; 3) utilization in the direct care element exceeds existing staffing; and 4) supplementation of alternate resources (e.g., Medicare, Medicaid, or private insurance) is required to provide comprehensive health care to eligible AI/AN.

The IHS requires a certified fiscal intermediary (FI) agent to provide a centralized medical and dental claims processing, reimbursement and reporting system for the PRC program…

Contractor’s qualification, capability and experience in Medical Claims Processing, Benefit Coordination and Payments including the ability to:

1. Conduct voucher examination activities for medical and dental claims.
2. Coordinate with providers and carriers for coverage information and payment calculation when conflicts occur.
3. Coordinate with other payers for payer of last resort provision requirements.
4. Verify authorizing authority for contracts, rate quote agreements and open market claims…

Contractor’s ability and methodology to implement and manage Systems Interoperability, Data Collection and Reporting.

1. The offeror should demonstrate the ability to provide, maintain and support the infrastructure, hardware, software, and communication network technologies for an automated claims processing system including equipment capacities, operational procedures and data storage.
2. The system’s capability to interface and operate with IHS systems to transmit payment and statistical data in compliance with Privacy Act and Health Insurance Portability and Accountability Act (HIPAA) requirements.
3. The system must also have the capacity to warehouse data and produce customizable workload, financial and statistical reports in multiple formats for various purposes. The capability statement must identify reports currently available…

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