Updated December 11, 2020
Notice ID: WTCHP-HPS-RFI_2020
Questions have been posted, and the RFI submission deadline has been extended to January 11, 2021. Also, the WTCHP is open for vendors to schedule a market research/industry meeting with us in January/February for a maximum of 2 hours session if they wish.
Posted November 25, 2020
Notice ID: WTCHP-HPS-RFI_2020
The purpose of this request for information (RFI) is to identify an experienced contractor to provide a robust end-to-end claims administration system, a comprehensive provider network solution for access to quality of care in the New York Metropolitan Area (NYMA), provide comprehensive and compassionate management of the WTCH Health Program’s limited benefit plans, provide support for program-wide utilization management and case management services, and provide claims and payment analytics and meaningful reports with solutions to improve efficiency and financial integrity.
The WTC Health Program is a limited-benefit program: treatment is covered only for a limited set of health conditions and only when a member’s condition is substantially likely to have been aggravated by, contributed to, or caused by the member’s 9/11 exposures. There is a list of applicable WTC-related health conditions that must be diagnosed by a Program provider; meet specified exposure, latency, and symptom-onset requirements; and be certified by the Program for the Program to cover the member’s treatment. Change this to benefit plans and covered conditions as shown and updated on our website. Currently, eight (8) Clinical Centers of Excellence (CCEs) in the New York metropolitan area (NYMA) and one Nationwide Provider Network (NPN) administer the benefits to Members. The complex limited-benefit structure of the Program poses a unique challenge when managing a member’s health plan benefits. The Program must ensure it is covering services and devices for only certified conditions, while also not impeding access beyond appropriate limits.
The current Health Plan Support (HPS) contractor oversees member enrollment and eligibility, the call center, treatment benefit plans, the claims adjudication system, and communications to all members, among many other tasks. The Clinical Centers of Excellence provide the monitoring, treatment, and case management to members within the NYMA and submit claims and benefit authorizations to the HPS for reimbursement. Certain treatment plans may require referrals to providers outside of the CCE which led to the establishment of the NYCA Provider Network. Services rendered by Network Providers outside of the CCE must be authorized at the CCE ensuring “medical necessity” for the WTCHP condition.
The Nationwide Provider Network (NPN) contractor manages the nationwide provider network and provides case management to members living outside of the NYMA. All monitoring and treatment are provided through the NPN. Authorizations for “medical necessity” are reviewed by the NPN contractor clinical staff.
The HPS also provides a claims data that allows stakeholders to run a variety of reports on claims for quality assurance purposes including data analysis for clinical reviews, cost analysis, program decisions. HPS staff provide general support to the WTC Health Program for clinical, operational, and customer service projects and daily requests.
The Program is interested in exploring different models for specifically administering the Claims Adjudication and Provider Network as a separate contract from the enrollment/eligibility, call center, and member communications. The WTC Health Program oversees all health plan operations and develops program policies. The WTC Health Program conducts and oversees all quality assurance activities related to benefits, escalated customer service, and other types of processes.
