Evaluation Tool

MississippiCAN ProgramRFP #20090127

Checklist for Completeness and Qualification of Offerors

RFP Section Statement/Question Reference/Comment Y/N1.3 Organizations Eligible to Submit Proposals (Documentation for each requirement)

Offeror has not been sanctioned by a state or federal government within the last 10 years.

Section 1.3Organizations EligibleTo Submit Proposals

Offeror must have experience in contractual services providing the type of services described in this RFP.

Section 5.4.3Corporate Experience

Offeror must be able to provide each required component and deliverable as detailed in the Scope of Work.

Section 5.2Transmittal Letter

Offeror must have at least 5 years of Medicaid experience Section 5.4.3Corporate Experience

4.2 Qualification of Offeror Each corporation shall report its corporate charter number in its transmittal letter or have attached to the transmittal letters reasons for exemption.


All corporations shall be in full compliance with all MS laws regarding corporation or formation of and doing business in MS and be in compliance with laws of the state in which they are incorporated, formed or organized.


Offeror must be licensed by MS Department of Insurance or in the process of obtaining a license from to be effective 10/1/09, and be licensed in another state.


4.3.2 Proposal Submission Requirements

Proposals must be submitted with components of the RFP clearly tabbed.

Document Inspection

An original and ten copies of the proposal under sealed cover must be received by DOM no later than 5:00 p.m. CST on March 16, 2009.

Document Inspection

Proposals should be delivered to Melanie Wakeland Document Inspection4.4.7 Rejection of Proposals Does the proposal contain unauthorized amendments to the

RFP requirements?Section 5.2

Transmittal LetterIs the proposal conditional? Section 5.2

Transmittal LetterIs the proposal complete? Document InspectionHas an authorized representative signed the proposal? Section 5.2

Transmittal LetterDoes the proposal contain false or misleading information?

MississippiCAN ProgramRFP# 20090127

Office of the Governor – Division of MedicaidDoes the Offeror currently owe the state of MS money?

4.4.8 Alternate Proposals Is there only one proposal submitted by the Offeror, its subsidiaries or related entities?


5.1 Introduction Does the technical proposal include a transmittal letter? Previously NotedDoes the technical proposal include an executive summary? Previously NotedDoes the technical proposal include a corporate background and experience?

Previously Noted

Does the technical proposal include a project organization and staffing plan?

Previously Noted

Does the technical proposal include methodology and a work statement?

Previously Noted

Does the technical proposal include project management and control?

Previously Noted

Does the technical proposal include a work plan and work schedule?

Previously Noted

5.2 Transmittal Letter Is the transmittal letter in the form of a standard business letter on the letterhead of the proposing company?

Section 5.2 Transmittal Letter

Is the transmittal letter signed by an individual authorized to bind the Offeror?


Does the transmittal letter identify all material and enclosures being submitted in response to the RFP?


Does the transmittal letter include a statement indicating that the Offeror is a corporation or legal entity?


Does the transmittal letter include a statement that the Offeror is registered or will be registered to do business in MS prior to the effective date of the contract and include their corporate charted number to do business in MS, if applicable? (If not yet registered to do business in MS at the time the proposal is submitted, there will not be a corporate charter number.)


Does the transmittal letter include a copy of the appropriate license from the Department of Insurance or other state license and application for license in the state of MS?


Does the transmittal letter include a statement that the Contractor agrees that any lost or reduced federal matching money resulting from unacceptable performance of a contractor task or responsibility, as defined in this RFP, shall be accompanied by reductions in payments to the Contractor?


Does the transmittal letter include a statement identifying the Section 5.2

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Office of the Governor – Division of MedicaidOfferor’s Federal tax identification number? Transmittal LetterDoes the transmittal letter include a statement that no attempt has been made or will be made by the Offeror to induce any other person or firm to submit or not to submit a proposal?


Does the transmittal letter include a statement of Affirmative Action that the Offeror does not discriminate in its employment practices with regard to race, color, religion, age (except as provided by law), sex, marital status,political affiliation, national origin, or disability?


Does the transmittal letter include a statement that no cost or pricing information has been included in this letter or any other part of the technical proposal?


Does the transmittal letter include a statement identifying all amendments to this RFP issued by DOM which have been received by the Offeror? If no amendments have been received, a statement to that effect should be included in the transmittal letter.


Does the transmittal letter include a statement that the Offeror has read, understands and agrees to all provisions of this RFP without reservation?


Does the transmittal letter include a certification that the Offeror’s offer will be firm and binding for 180 days from the proposal due date?


Does the transmittal letter include a statement naming any outside firms responsible for writing the proposal?


Does the transmittal letter include a statement agreeing that the Contractor and all subcontractors will sign the Drug Free Workplace Certificate (Exhibit 1)?


Does the transmittal letter include a statement that the Offeror has included the signed DHHS Certification Regarding Debarment, Suspension, and Other Responsibility Matters for Primary Covered Transactions (Exhibit 2) with the Transmittal letter?


Does the transmittal letter include a statement that all proposals submitted by corporations must contain certifications by the secretary or other appropriate corporate official other than the corporate official signing the corporate proposal that the corporate official signing the corporate proposal has the full authority to obligate and bind the corporation to the terms, conditions, and provisions of the


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Office of the Governor – Division of Medicaidproposal?Does the transmittal letter include a statement that proposals submitted include a statement that the Offeror presently has no interest and shall not acquire any interest, direct or indirect, which would conflict in any manner or degree with the performance of services under this contract, and it shall not employ, in the performance of this contract, any person having such interest?


Does the transmittal letter have a statement that If the proposal deviates from the detailed specifications and requirements of the RFP, the transmittal letter explains these deviations?


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Office of the Governor – Division of Medicaid

MississippiCAN ProgramRFP #20090127Evaluation Tool

Sections 5.3 – 5.5

Please note: Response elements are not necessarily exact requirements but are intended to prompt the evaluators on the kinds of information which could be appropriately included in proposals.

RFP Section # Statement/Question Reference/Comments Maximum Point Value

Maximum Possible Points for Executive Summary: 1005.3 Executive Summary

1. Does the Executive Summary condense and highlight the contents of the Technical Proposal in such a way as to provide a broad understanding of the entire proposal?

5

2. Does the Executive Summary include a clear statement of the Offeror’s understanding of purpose and goals?

15

3. Does the executive Summary include a narrative description of the proposed effort, items to be delivered, and services to be provided?

10

4. Does the Executive Summary include a description of the Offeror’s coordinated care plan delivery system?

15

5. Does the Executive Summary include a brief description of the Offeror’s qualification with the Offeror’s key strengths highlighted?

20

6. Does the Executive Summary include a description of the Offeror’s experience and familiarity with the medical, educational, social, and economic needs of the population to be served?

15

7. Does the Executive Summary include a description of the Offeror’s ability to further the Division’s goals for this program?

20

8. Is the Executive Summary more than four single-spaced typed pages in length?

If Summary is over long, reduce number of points awarded in this section

Minus 10 points

Maximum Possible Points for Corporate Background: 70 Points5.4Corporate Background

1. Does the Corporate background include information about all current and recent Medicaid and related projects dating back to at least January 2004 and through the present?

What are they?

Preferred response includes Medicaid coordinated care experience with target populations or equivalent in more than one other site and for more than 5 years.

14

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Office of the Governor – Division of Medicaid2. Does the corporate background include the date the corporation

was established?

What is it?

2

3. Does the corporate background include the principal place of business?

Where is it?

2

4. Does the corporate background include the location of the proposed administrative offices for this project?

Where is it?

Response must include administrative office in Jackson.

5

5. Does the corporate background include the description of Ownership?

What is it?

2

6. Does the corporate background include experience in systems capabilities to collect, report and monitor quality and operational indicators?

How many years of experience?

Preferred response includes more than 5 years experience serving more than one program.

12

7. Does the corporate background include total number of staff dedicated to administering MississippiCAN?

How many are there and in what categories?

Preferred response will include key positions as described in the RFP and dedicated staff for provider recruitment/relations.

9

8. Does the corporate background include performance history and reputation?

What is it?

6

9. Does the corporate background include current products and services, in particular programs for healthy behaviors, wellness and disease management?

What are they?

Preferred response includes services specifically for the targeted Medicaid populations. Programs that link to existing community resources and groups especially desirable.

9

10 Does the corporate background include professional accreditations pertinent to the services provided in this RFP?

Preferred responses include NCQA accreditation at the

9

6



What are they?Excellent level.

11 Does the corporate background include information on any contractual termination for cause within the past five (5) years? What were they?

If Offeror responds positively to this question, reduce number of points for this section by 14.

Minus 18 points

Maximum Possible Points for Financial Soundness: 2005.4.2 Financial Statements

1. To reviewers: You are not asked to score this section of the RFP. It will be reviewed against objective criteria by Milliman. Up to 100 points will be awarded based on the degree to which bidders meet NAIC Risk Based Capital guidelines. Up to 100 points will be awarded based on the degree to which bidders meet liquidity, IBNR, and net worth guidelines.

Maximum Possible Points for Corporate Experience: 70 5.4.3 Corporate Experience

1. Does the corporate experience section present the details of the Offeror’s experience with the scope of work required by this RFP?

What is the experience?

Response addresses Medicaid specific experience at a minimum and preferred response includes experience with targeted populations.

20

2. Does the corporate experience show their last five (5) years of Medicaid experience presented chronologically?

What is it?

8

3. Does the corporate experience provide a list of at least the last three (3) most recent, relevant contracts to serve as corporate references include the client’s name and address and the current telephone number of the client’s responsible project administrator or of a senior official of the client who is familiar with the Offeror’s performance and who may be contacted by DOM during the evaluation process?

Does the corporate experience provide the following for each experience?

customer name; customer references (including phone numbers); description of the work performed; time period of contract; staff months expended? personnel requirements publicly funded contract cost

Reference checks to occur during evaluation and scoring will depend on the quality of references.

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Office of the Governor – Division of MedicaidWhat are they?

Maximum Possible Points for Project Organization and Staffing: 1105.5 Project Organization and Staffing

1. Does the proposal include project team organization, charts of proposed personnel and positions, and job descriptions of key management personnel?

20

2. Does the proposal include the following job descriptions?Executive Positions:

Full time Chief Executive Officer, and/or Chief Operations Officer for the Mississippi program located in Mississippi

Chief Financial Officer Chief Medical Officer located in MS Chief Information Officer

Administrative Positions: Full time Provider Services Manager located in MS Full time Member Services Manager located in MS Quality Management Coordinator Utilization Management Coordinator Maternal Health/EPSDT Coordinator Complaint and Grievance Coordinator Claims Administrator Other key personnel as identified by CCO

30

3. Resumes for key staff positions. Does each resume include: Experience working with Medicaid programs? Experience working with coordinated care organizations? Relevant training and accreditation? Experience in managing large-scale contractual service

projects? Three references?

Preferred response has the key positions already filled with staff that have prior Medicaid coordinated care experience.

60

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Section 5.6


5.6 Methodology/Work Statement

# Statement/Question Response Elements

Award 1 - 5 Pts (1 being least

effective, 5 being most effective)

Benefits 1. Describe the approach you will take to inform members about covered health services including covered pharmacy services. (Limit to three pages.)

Information on covered services is Included in new member materials Covered in new member welcome calls Covered in periodic newsletters Included as part of case management and

disease management program Included in special calls, e.g. calls to

members inappropriately using ER or members who have not seen PCP in past 6 months

2. Describe policies, procedures, and processes you will put in place to encourage members to engage in wellness programs including the approach you intend to use to ensure that members receive a physical exam annually and appropriate intervention to ensure improved health outcomes. (Limit to two pages.)

Re encouraging member to engage in wellness Included in new member materials Covered in new member welcome calls Covered in periodic newsletters Incorporated into community outreach

activities Appropriate incentives offered e.g. discounts

at gyms, discounts at weight reduction programs

Specific outreach to members with identified diseases or conditions e.g. smokers, diabetics, etc.

Re members receiving physical exams Included in new member materials Covered in new member welcome calls

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Covered in periodic newsletters Targeted calls to members for whom claims

data review indicates no physical exam has occurred; calls focus on identifying and overcoming obstacles to care e.g., transportation support supplied if necessary

Re: interventions to ensure improved health outcomes Clear program to collect data and outreach

to members and providers

3. Describe your plan to create and maintain collaboration with providers of mental health services in order to coordinate care for members. (Limit to two pages.)

Collaboration plan described, including Meeting frequency Attendees Likely agendas and issues to be addressed Bidder’s similar experience elsewhere

4. Describe any benefits over and above the required benefits that you propose to provide to members. (Limit to two pages.)

Over and above benefits should tie to Participation in wellness programs including

physical exams Compliance with disease and case

management programs5. Describe the process you will have in

place to ensure that any new member has an appointment scheduled with the selected medical home within at least 120 days of enrollment.

Process to include Communication with DOM to ensure prompt

receipt of info on medical home selection Initial telephonic outreach with new member

calls Method to identify when an appointment has

not been scheduled Targeted outreach and interventions

Administrative Services

6. Describe your member call center operations including:

Location of operations (If out of state, describe how it will accommodate services for Mississippi.)

Hours of operation are 24/7 Location: Mississippi location is ideal,

domestic location strongly preferred. Minimum performance standards:

o Abandon rate less than or equal to 5%

10






Standards for rates of response (live answer, incomplete calls, speed of answer, average length of call, etc.) and measures to ensure standards are met

Accommodations for non-English speaking, hearing impaired, and visually impaired callers

Staffing ratios including number of call center employees per enrolled member and supervisor to staff ratio

Describe the process in place to insure that member calls pertaining to immediate medical needs are properly handled.

Training program for call center employees including, but not limited to, cultural competency

(Limit to four pages.)

o Service level – 85% of calls answered within 30 seconds

o Speed of answer – 30 seconds If automated call answering for frequent

questions, response describes questions handled automatically and options for over-ride.

Re language capabilities, staff should include bi-lingual Spanish and Vietnamese speaking staff

Staffing ratios:o Description of employee per member

staffing ratio and rationale.o 10 employees per supervisor

Immediate medical needs calls transferred to decision making clinician within 1 hour.

Well established and described training program, including cultural competency.

7. Describe the informational materials you propose to send to new members. Address language alternatives that will be available and how you will ensure that reading levels will be at a sixth grade level. (Limit to two pages, excluding copies of materials.)

Credible materials described and presented in mock up form.

Reading level addressed

8. Describe your process to produce and distribute identification cards and member information to members within 10 business days of enrollment.(Limit to two pages.)

Credible process described. Response includes actions CCO will take

when the address of record is inaccurate.

9. Describe your provider call center operations including:

Hours of operation Location of operations (If out of

Hours of operation are 9-5 M-F Location: Mississippi location is ideal,

domestic location strongly preferred. Minimum performance standards:

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state, describe how it will accommodate services for Mississippi.)

Standards for rates of response (live answer, incomplete calls, speed of answer, average length of call, etc.) and measures to ensure standards are met

Job qualifications for call center employees

Staffing ratios including number of call center employees per enrolled member and supervisor to staff ratio

Training program for call center employees including cultural competency

The extent to which you plan to use electronic means of communication to respond to provider inquiries and how you propose to do so

(Limit to three pages.)

o Abandon rate less than or equal to 5%

o Service level – 85% of calls answered within 30 seconds

o Speed of answer – 30 seconds Credible description of job qualifications Staffing ratios:

o Description of employee per member staffing ratio and rationale.

o 10 employees per supervisor Well established and described training

program, including cultural competency. Automated call answering for frequent

questions desired; response describes questions handled automatically and options for over-ride.

Web based mechanism to answer frequent questions, especially related to claims payment desired; response describes questions handled and documentation.

10.

Provide a general Management Information System (MIS) description including:

A systems diagram that describes each component of the management information system and all other systems that interface with or support it

How each component will support the major functional areas of the MississippiCan program

(Limit to 10 pages, including diagram.)

Full response to question includeso Systems diagramo Description of components and other

system interfaces including Workflow management Enrollment Benefits administration Provider data base Fee schedules Claims adjudication Fee for service and

capitation payments Care and utilization

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management Quality management Call management

o How each component is used to support functional areas

o Transmission of data to subcontractors and subcontractor systems capability.

Desired response shows system in place and functional for at least two years in another location.

11.

Describe modifications or updates to your (MIS) that will be necessary to meet the requirements of this program and your plan for their completion. (Limit to four pages.)

Desired response is that no modifications or updates are required.

If modifications or updates required, they should be minor and NOT in areas of enrollment or claims payment.

12.

Describe your claims processing operations including:

The claims processing systems that will support this program

Standards for speed and accuracy of processing and measures to ensure that standards are better or no less than Medicaid fee-for-service program


Claims processing system should be a recognized system with a demonstrated track record e.g. TBD

Standards meet or exceed the following:

o Claims Adjudication - The Contractor must properly adjudicate 90 percent of all clean claims within 30 calendar days of receipt, except in those cases where DOM approves a longer suspense period. A clean claim is one that has no defect, impropriety, or lack of any required substantiating documentation; however, this would include claims that require manual pricing.

o Claims Adjudication - The

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Contractor must properly adjudicate 99 percent of all clean claims within 90 calendar days of receipt, and all claims within one year of receipt, except in those cases where DOM approves a longer suspense period. A clean claim is one that has no defect, impropriety, or lack of any required substantiating documentation; however, this would include claims that require manual pricing.

o Paper Claims - Claims must be entered for processing within 15 calendar days of receipt

13.

Describe your method and process for capturing third party resource and payment information from your claims system for use in reporting cost-avoided dollars and provider-reported savings to DOM. Explain how you will use such information. Describe the process you use for retrospective post payment recoveries of health-related insurance as well as your process for adjudicating claims involving third party coverage.(Limit to three pages.)

Understanding that Medicaid is the payer of last resort

Uses State third party resource fill as a primary data source to update member other insurance data; updates to State third party resource files occur daily

Routine and periodic survey of membership for other coverage

Claims processing automatically checks for other coverage with payments made assuming CCO is the secondary payer is other coverage is identified.

Claims for care related to accidents are paid as received and followed up on subsequently.

14.

Describe your approach for ensuring complete encounter data is submitted accurately and timely to DOM consistent with the required formats. Include in your

Re complete data Response includes process to monitor data

submission from providers, including identification of outliers and interventions.

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response how you propose to monitor data completeness and manage the non-submission of encounter data by a provider or a subcontractor. (Limit to four pages.)

CCO contracts with providers and subcontractors include encounter submission requirements.

Re accurate and complete submission EDI process described and in compliance

with Mississippi guidelines Experience and performance in other

locations described 15.

Describe the capability your management will have to access a database of service information to create ad hoc reports for both Offeror management and DOM. Include a description of the system and software, an overview of the data that will be held, and the resources and capability you will have to use large amounts of data to create ad hoc reports.(Limit to five pages and a list of anticipated reports.)

Credible system and process described that includes The data warehouse, its libraries and data

stored in the libraries Frequency of updates The business intelligence unit that uses the

data Software used Ability to access subcontractor data Experience in other settings Examples of problems or issues identified or

interventions monitored through use of this capability

16.

Explain the process you will put in place to maintain your provider file with detailed information on each provider sufficient to support provider payment, meet all federal and DOM reporting requirements, and cross reference to state and federal identification numbers to ensure excluded providers are identified.(Limit to two pages.)

Response includes Process to gather information including

o Annual frequency at a minimumo Mode of data collection e.g.,

electronic, part of routine visitso Process in special situations

including at academic medical centers for residents and changes in staff at predictable times (July 1)

Process to cross walk datao Process to cross walk to federal ID

numberso Process to cross walk to state ID

numbers

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Process to contact/interact with providers when problems are identified

17.

Describe the process you will use to utilize the eligibility and enrollment files from DOM to manage your membership. Include the process for resolving discrepancies between these files and your internal membership records.(Limit to two pages.)

Response includes description of Weekly automated enrollment file processing Weekly exception/error processing Manual processing/reconciliation for any

outstanding item including outreach to members and communication with DOM

Weekly updated communications to providers and subcontractors

18.

Describe the fraud and abuse program that you will implement including:

Fraud detection methods that will be used

Steps that will be taken if fraud is detected including DOM notification

Plan for compliance with the Exclusion Program of the United States Department of Health and Human Services Office of the Inspector General or any provider restrictions imposed by the state

(Limit to two pages.)

Dedicated unit should be described that Uses a plan that complies with the

guidelines Integrates evaluation of claims data,

billing patterns, and member complaints Includes a training program for CCO

staff on identifying fraud and abuse

19.

Describe your emergency response continuity of operations plan. Attach a copy of your plan or, at a minimum, summarize how your plan addresses the following aspects of pandemic preparedness and natural disaster recovery:

Employee training Identified essential business

functions and key employees within your organization necessary to carry them out

Desired response includes both a short summary and a full disaster recovery plan attached.

Acceptable response includes a summary of each of the elements described:

o Employee trainingo Identified essential business

functions and key employees within your organization necessary to carry them out

o Contingency plans for covering

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Contingency plans for covering essential business functions in the event key employees are incapacitated or the primary workplace is unavailable

Communication with staff and suppliers when normal systems are unavailable

Specifically address your plans to ensure continuity of services to providers and members

How your plan will be tested (Limit to five pages.)

essential business functions in the event key employees are incapacitated or the primary workplace is unavailable

o Communication with staff and suppliers when normal systems are unavailable

o Specifically address your plans to ensure continuity of services to providers and members

o How your plan will be tested

20.

Describe how and where records will be maintained and the process and timeframe for retrieving records needed or requested by DOM or other State or external review representatives.(Limit to two pages.)

Credible response described. Desired location is in Mississippi Desired timeframe is one week or less.

21.

Describe your plans to establish an Administrative Office within 15 miles of Jackson MS as is required by the RFP. Also describe the office within that space that you will make available to DOM staff. (Limit to one page)

Credible approach described.

Provider Network

22.

Describe your plan to ensure that your provider network meets the network and access requirements of the Program. Describe the method you plan to use on an ongoing basis to assess and ensure that DOM’s network standards are maintained, including standards related to :

Travel time Appointment access Cultural competency After hours access

Adequate response will include the following by the CCO Compliance is measured annually Travel time is measured using GeoAccess Appointment access is measured using on-

site appointment log review and secret shopper calls

Cultural competency is measured using on-site assessment

FQHC and RHC inclusion is measured by assessing contracts in place vs. existing sites

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Inclusion of FQHCs and RHCs Inclusion of out-of-state providers

for medically necessary services Inclusion of non-hospital urgent

and emergent care providers (Limit to eight pages.)

Annual review of necessary services as contracts with out of state providers

Annual review of available non-hospital and urgent care providers and contracts in place

23.

How do you use GeoAccess mapping to ensure network adequacy? Using providers with whom you have signed letters of intent, provide individual GeoAccess maps for hospitals, pediatricians, obstetricians, medical homes providing primary care, FQHCs, RHCs and dentists.(Limit to two pages.)

Rank responses based on number of providers in each region to serve the targeted population.

24.

Should your organization be unable to secure an agreement with a key provider type in a given geographic area, what strategies will you use to ensure that members have access to care?(Limit to two pages.)

Credible response will include Single case agreements at the Medicaid rate

or an enhanced rate locally An out of area provider with transportation

support provided by the CCO

25.

Describe any provider incentive programs you plan to implement in order to improve access.(Limit to two pages.)

At a minimum, incentives to Increase the number of MississippiCAN

members Extend hours of operation

26.

Describe the approach you will take to assess provider satisfaction including tools you plan to use, frequency of assessment, and responsible parties.(Limit to two pages.)

Minimum response includes Annual provider representative visits Annual survey by Provider

Relations/Services unit Discussions at Quality Assurance committee

meetings Periodic focus groups with physician office

staff27.

Describe the mechanisms you will use to communicate with providers and the content you anticipate including in

Mechanisms to include Quarterly newsletters Special issue “faxes”

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communications.(Limit to three pages.)

Stuffers with claims payments E-mail communicationsContent to include Medical standards Special areas of health focus e.g. diabetes

screening Administrative issues

28.

Explain your process for ensuring that providers are enrolled in Medicaid and have a valid identification number.(Limit to two pages.)

Response includes Cross walk of provider file against state file

to identify any outliers Provider network representative outreach to

providers to confirm data, identify obstacles, and develop approach to overcome obstacle.

29.

Please submit copies of your standard provider contracts.

Legal to review contracts to ensure appropriate elements in place

30.

Provide a listing by provider type/specialty of the providers from whom you have received a signed letter of intent to participate in your provider network.

Rank by number of signed letters of intent in necessary specialties.

Care Management

31.

For members who have not selected a medical home within 30 days of enrollment, describe the process you will use to assign members to a medical home within 60 days of enrollment. Describe how you will inform medical home (primary care providers) of new members. (Limit to three pages.)

Assignment process response should address Geographic match Language/cultural match Family member match If available, health issue matchInformation process should address initial contact and follow up contacts to ensure appointments.

32.

Will your program require referrals from primary care providers in order to authorize services from specialists? Under what circumstances, if any, may a specialist be designated as a member’s primary care provider? (Limit to two pages.)

In general, responses should Require referrals for most services but not

certain basic services such as ob-gyn Allow specialists to act as a PCP for chronic

medical conditions such as HIV

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33.

Describe the policies, procedures, and processes you will use to conduct outreach and follow up to ensure that members receive all recommended preventive and medically necessary follow-up treatment. (Limit to two pages.)

Responses should include Scanning of claims data to ensure age and

sex appropriate preventive care services are provided

Scanning of claims data to ensure disease state appropriate services are provided.

For members who have not received care, correspondence to providers and members re need for care.

For members who do not seek care, outreach calls.

Ideally, a provider incentive program to reward for outreach by providers for preventive and medically necessary services to members.

34.

Describe the process and criteria used for case management, including how you will case manage and what services you will provide. Address the following issues in the response:

How will you identify potential case management situations

If you use a list of diagnoses to identify cases for management and if so provide the list

Once a case is identified, how you determine whether to pursue the case for management

How case managers interact with patients and the patients primary care physician, family, and other attending physicians

What procedures and processes are used to ensure that all medically necessary services are provided

Any software you use to identify

Clear and specific responses to each of the items posed. Responses should use claims and encounter

data to identify case management situations. Case manager interactions should be

multimedia, i.e. electronic, automated phone contact, personal phone contact.

All interactions should be documented. Approach should include disease/condition

specific initiatives e.g. lay outreach for pregnancy.

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high risk members and track outcomes including predictive modeling software.

Specifically address programs for pregnant women, neonates, members with mental health needs and members in need of organ transplants or renal dialysis.(Limit to ten pages.)

35.

Describe the policies, procedures, and processes you will use to provide disease management for members with diabetes, asthma, hypertension, obesity, congestive heart disease, hemophilia at a minimum. Specifically address:

Identification and outreach to members requiring disease management services

Stratification (risk levels) and interventions you will implement for each risk level to provide disease management services for these members

Facilitation and monitoring of recipient compliance with treatment plans

Coordination with providers of care

(Limit to six pages.)

Clear and specific responses to each of the items posed. Responses should use claims and encounter

data to identify disease management situations.

Interactions with members should be multimedia, i.e. electronic, automated phone contact, personal phone contact.

All interactions should be documented.Approach should include disease specific member identification, stratification, and interventions.

36.

For members with special needs, describe the policies, procedures and processes you will put in place to ensure coordination of care across the care continuum. Describe how you will assist members with special needs in identifying and gaining access to community resources that may provide

Member identification processes are described including referrals from DOM, internal Member Services, providers; encounter and claims data; etc.

Members are linked to a specific support within the organization such as a case manager or EPSDT outreach worker who is accountable for arranging for care

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services that the Medicaid program does not cover. (Limit to three pages.)

CCO establishes a community resource “book” or equivalent and a program to maintain productive working relationships to facilitate gaining access to services.

37.

Describe your approach to utilization management, including:

Lines of accountability for utilization policies and procedures

Data sources and processes to determine which services require prior authorization and how often these requirements will be re-evaluated

Process and resources used to develop utilization review criteria

Prior authorization processes for members requiring services from non-participating providers or for members who require expedited prior authorization

Processes to ensure consistent application of criteria by individual clinical reviewers


UM must be directly accountable to a physician.

Description should be comprehensive, including all departments that are involved including pharmacy

Use of objective, external guidelines e.g. Interqual, to guide decisions

Involvement of advisory groups to address issues of emerging technology

Ideally, prior authorization mirrors DOM’s prior authorization requirements for Outpatient Physical, Occupational and Speech Therapy, Inpatient Acute Care, Durable Medical Equipment, Home Health, Private Duty Nursing and Organ Transplant.

Method to ensure inter-rater reliability and frequency of evaluation.

38.

Describe the policies and procedures you will put in place to control avoidable hospitalization and hospital readmissions. (Limit to two pages.)

Prospective and concurrent review processes are in place for all elective admissions

Discharge planning is comprehensive to avoid readmission

Data is reviewed to identify individual cases of inappropriate admissions and corrective actions taken

Data is reviewed to identify trends of inappropriate utilizations with corrective actions

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Reference to disease state management and case management programs

Health and wellness initiative for members39.

What is your definition of medically necessary care? Describe your process for developing and periodically reviewing and revising the definition. Describe the degree to which your definition is consistent with or differs from DOM’s definition of medical necessity. (Limit to two pages)

Ideal response uses the same definition used by MS DOM, below:

o Services or supplies that: are proper and needed for the diagnosis or treatment of your medical condition, are provided for the diagnosis, direct care, and treatment of your medical condition, meet the standards of good medical practice in the local area, and are not mainly for the convenience of the patient or the doctor. If different from DOM’s definition, response to include complete references for sources on the definition, methodology to review and revise.

If different from DOM’s definition, response should be that differences are minor.

40.

Describe the management techniques, policies, procedures, or initiatives you will put in place to avoid unnecessary emergency room utilization.(Limit to three pages.)

Response should be multi-dimensional, addressing members, providers, and community factors Members encouraged to establish

relationship with medical home and CCO ensures an appointment

Claims data reviewed to identify members with inappropriate ER use and outreach conducted to

o Re-educate members re benefits and use of services

o Re-encourage relationship with medical home

o Connect members to disease state

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management if appropriate Provider profiles include member ER use

rates with appropriate outreach including corrective actions if inappropriate practices identifies.

Provider access issues investigated.41.

Describe your process for insuring that non-participating providers who provide emergency services to members are paid on a timely basis. Also describe your process to insure appropriate communication with the provider, follow-up communication with the members’ medical home, and follow-up care for the member. (Limit to two pages)

Claims for emergency services by non-par providers are flagged for special handling.

Claims are forwarded to medical management for prompt review and authorized for payment

Medical management assigns a staff member to outreach to the member and the provider to expedite transfer of information to the member’s medical home

Ideally, the staff member follows up to ensure there has been follow up care at the member’s medical home.

42.

If you will be using a Pharmacy Benefit Manager (PBM), describe the arrangement and include a copy of the contractual agreement.(Limit to one page.)

PBM has demonstrated experience Assignment of responsibilities is clear in the

contract; contract includes performance standards and penalties if standards not met.

43.

Provide a copy of the Preferred Drug List (PDL) you will utilize and describe the exception process if a non-preferred drug is used. (Limit to two pages.)

PDL included The prior authorization process described is

not overly cumbersome Emergency authorization process and

response described44.

If applicable, explain who audits the PBM and on what schedule. Are the audits based on Mississippi state laws and regulations or are audits based on the requirements of the state of domicile? Are audit results reported and on what schedule? What sanctions are imposed if improper activities are detected?

Audit conducted by CCO or designee with experience in PBM auditing

Mississippi audit standards preferred Audits happen bi-annually Financial sanctions are in proportion to

improper activities

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(Limit to two pages.) 45.

Describe the rebate management program you will put in place. Include the drugs to be included, formulas that will be used to calculate rebates, dispute resolution.(Limit to three pages.)

General description of program and what’s covered: brands and/or generics

Contracts with manufacturers in place Contracts specify drugs covered and

formulas for rebates with target rebates at AWP – 14% for brand and AWP less 35% as target numbers.

46.

Provide a full description of the drug utilization program you will put in place. (Limit to three pages.)

Concurrent review in place at point of service via clinical edits in claims payment system

Retrospective review of all drugs ordered and filled

Special reviews of high cost/high frequency drugs.

47.

Describe how you will identify provider utilization patterns to improve care and reduce costs.(Limit to two pages.)

Response should integrate use of following reports described elsewhere Physician provider profiles, including ER use Pharmacy drug utilization review reports Data from preventable serious medical error

investigationsResponse should actions resulting from data review including actions such as Policies and procedures for data sharing,

requests for corrective actions, and follow up as appropriate with individual providers

Development of incentive programs Development of educational programs

48.

Describe your plan to monitor use of psychotropic drugs in order to assist in the coordination of care for members with mental health needs.

Routine claims review to identify members taking psychotropic drugs

Outreach to providers to ensure resources available to providers and members to ensure appropriate levels of care

If deficiencies identified, policies and procedures in place to support putting proper coordination of care in place and connection

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to mental health service providers as appropriate.

49.

Describe the policies and procedures you will put in place to develop and maintain a comprehensive health education program for members. Please address:

Your rationale for selecting areas of focus

How you will ensure that reading levels are at a sixth grade level

The language alternatives that will be available to non-English speakers/readers

How visually impaired will be accommodated


Use claims and member demographic data to identify topics by geographic area for focus.

Identifying existing community resources which to work to develop most effective programs.

Integrate health education with community events

Include materials and programs to support providers in educating members

Possibly include a member advisory group Address reading levels and non-English

materials

Quality Assurance

50.

Provide an overview description of your proposed quality assurance program. Include the following in your description:

The lines of accountability for the program

How you will select areas of focus

How you will use evidence based practices in developing your quality assurance program

How you will use data to design and implement your quality assurance program

What staff will be assigned to this program and their qualifications

How will you ensure separation of responsibilities between utilization management and quality assurance staff?


Quality assurance activities are under the direct responsibility of the Board.

Program is based on health status data obtainable within the Plan.

Health services data, both within the plan and in the literature, is used to design the QA program

Staff has appropriate qualifications: program is under the direction of a qualified physician with nurses and other health care professionals involved.

There is a clear separation between UM and QA activities.

51 Describe the policies and procedures you Claims based system to identify problem

26






. have in place to reduce health care associated infection, medical errors, preventable serious adverse events (never events) and unnecessary and ineffective performance in these areas.(Limit to two pages.)

cases e.g. inconsistent admission and discharge diagnoses

Policy (consistent with CMS guidelines) not to pay for services that are harmful, inferior quality, medically unnecessary

Internal program to identify and investigate events that point to possible preventable serious adverse events such as rapid re-admits, outlier stays, member complaints

Up front clinical edits to prevent drug/drug or drug/food interactions, inappropriate dosing, age appropriate dispensing

52.

Describe in detail how you propose to use encounter data, trending and other ad hoc reports to systematically and objectively monitor, measure, and evaluate the quality and appropriateness of care and services provided. Specify the reports you propose to use.(Limit to four pages.)

Describes data warehouse and the various data elements included

Address the software used to analyze data Address staff in place to accomplish these

tasks Describe the purposes for which the data will

be used e.g. designing provider incentives, informing case and disease management programs, developing health education programs, evaluating quality of care, etc.

Describe at least sample reports that would be available

53.

Describe the process you will have in place to notify providers of new practice guidelines and to monitor implementation of those guidelines.(Limit to two pages.)

Process in place to monitor literature and cull data on new practice guidelines.

Newsletter/fax/other mechanisms in place to communicate new practice guidelines

Data analysis allows immediate follow-up to assess implementation

Corrective action plans will be prepared as necessary.

54.

Describe the policies, procedures, and processes you will use to conduct provider profiling to assess the quality of care delivered.(Limit to two pages.)

Describe providers for whom profiles are prepared; at a minimum should include PCP profiles, ideally should also include high volume providers

Describe source data for the reports

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Describe report content and frequency; ideally provide a sample report

Guidelines used to determine problematic performance e.g., comparison to objective measures, comparison to peers

Actions taken if problem performance is identified

55.

Describe any provider incentive programs you propose to implement to improve the quality of care provided to members.(Limit to two pages.)

Year 1 actions likely focus on data collection Program to be data based and outcome

focused Anticipated programs should focus on target

population requirements e.g. early prenatal care, chronic care management

56.

Describe how you will encourage providers to use electronic medical records.(Limit to two pages.)

Financial support or financial incentives desired

57.

What methods will you use to ensure the quality of care delivered by out-of-network providers?(Limit to two pages.)

If emergent care, Care subject to concurrent review once case

is known All medical records requested and (1) sent to

medical home for continuity of care and (2) reviewed for quality of care.

If referred care, Care management staff arrange for services

in advance to ensure clear understanding of services required and lines of communication established

Care subject to concurrent review and as appropriate involvement of medical home

58.

Describe your methodology to assess disparities in treatment among disparate races and ethnic groups and correct those disparities.(Limit to four pages.)

Method to assess problem: Ideally, analysis of claims data At a minimum, use of specific public health

and local demographic dataAnticipated intervention:

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Targeted member education materials Targeted community events. Hiring practices that support cultural and

sensitivity to racial and cultural issues. Cultural sensitivity training for staff and

provider network. Targeted network recruitment to include

practitioners sensitive to issues of disparity in care.

Targeted health intervention efforts around diseases more prevalent among minorities.

59.

Describe your complaint and grievance process specifically addressing:

Compliance with State requirements as described on DOM’s website

Levels of review and timing Process for expedited review How complaints and grievances

are tracked and trended and how you use the data to make changes to procedures and processes


Process complies with DOM requirements and includes

o Before the hearing, the beneficiary and/or his or her legal representative have the right to review the case file and all records that will be used at the hearing in support of the adverse decision.

o The Hearing Officer must be impartial and cannot engage in ex parte communications with either side.

o The hearing decision is based solely on the evidence produced at the hearing and the record case.

o Appeals may be evaluated by an appropriate independent clinical peer professional in the same or similar specialty as would typically manage the case being reviewed, or another licensed health care professional. In no case shall the peer professional have been involved in the initial adverse determination.

o An administrative hearing is not

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required if the sole issue is a Federal or State law requiring an automatic change adversely affecting some or all beneficiaries.

o A request for a hearing may be denied or dismissed if the beneficiary and/or legal representative withdraws the request in writing or fails to appear at a scheduled hearing without good cause.

Expedited review should be accomplished within 48 hours

Complaints and grievances should be well integrated into the QA process

60.

Describe how you will monitor customer satisfaction with your performance and services. Include how this data is used in ongoing quality improvement efforts.(Limit to two pages.)

Do you want to require participation in CAHPS?

Annual survey of membership including description of how survey will be administered, how questions will be designed, and incentives for responding

Annual survey of providers including description of how survey will be administered, how questions will be designed, and incentives for responding

Description of plan on use of data Evidence of how bidder has used this data in

other settingsSubcontractors

61.

If you propose to use subcontractors to provide any of the services called for in this RFP, provide a listing of those subcontractors with their experience in providing care to Medicaid members and a brief description of the services they will provide if not already described.

Subcontractors should not be used for “core” CCO services such as utilization management, case management, quality management, provider recruitment.

Prior Medicaid experience highly preferred.

62 Describe your subcontractor oversight Contracts with subcontractors should include

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. program. Specifically describe how you will:

Ensure receipt of all required data including encounter data

Ensure that utilization of health care services is at an appropriate level

Ensure delivery of administrative and health care services at an acceptable or higher level of care and meets all standards required by this RFP and your internal standards...

Ensure adherence to required complaint and grievance policies and procedures

compliance with all requirements in the contract between DOM and the CCO. Program described for on-going monitoring

of subcontractors Responsibility for oversight clearly assigned.

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Sections 5.7 – 5.8


RFP Section # Statement/Question Reference/Comments Maximum Point Value

Maximum Possible Points for Project Management and Control: 505.7 Project Management and Control

1. Does the proposal contain Sign-off procedures for completion of all deliverables and major activities?

5

2. Does the proposal contain a method to manage performance standards, milestones and/or deliverables?

Is there a Gant chart or work plan with dates and responsible parties to manage the project? Do the dates seem reasonable and meet the DOM deadlines?

5

3. Does the proposal have a way to assess project risks and an approach to managing them?

Is there a contingency plan that explains what will happen if deadlines are not met? What safety measures are built in that will minimize the risk of services not being provided?

10

4. Does the proposal have a plan for anticipating problem areas and the approach to management of these areas, including loss of required personnel?

Preferred response will include the potential to pull staff from other parts of their organization to temporarily fill key positions.

10

5. Does the proposal have a project status reporting, including examples of types of reports?

5

6. Does the proposal have an approach to problem identification and resolution?

10

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7. Does the proposal have an approach to DOM’s interaction with contract management staff?

5

Maximum Possible Points for Work Plan and Schedule: 505.8 Work plan and Schedule

1. Does the proposal include a work plan, showing the start and end dates for all tasks and subtasks, indicating the interrelationships of all tasks and subtasks, and identifying the critical path as well as all responsibilities, milestones, and deliverables outlined in this RFP?

20

2. Does the proposal include a Gantt chart, showing the planned start and end dates of all tasks and subtasks?

15

3. Does the proposal provide that all deliverables have a minimum of five (5) workdays for review by DOM?

15

33

Business

Evaluation Tool