RFP Section Question Response - wcb.ny.gov · Contractor’s cost proposal shall include: 1. A definition regarding what constitutes a single medical bill and a single ... TPA. RFP

New York State Workers Compensation Board Third Party Administrator Services (TPA) RFP C140734 April 17, 2018

RFP Section Question Response

1.

1.2 Summary of Scope of Services, Page 6; 2.2 Administrative Requirements and Information, 2.2.15 Business Participation Opportunities for MWBEs, page 13

With regard to Service Lot #2 B/RB (Medical Bill Review Services, we would like further clarification on the MWBE goal and the use of subcontractors. The RFP states: Business Participation Opportunities for MWBEs For purposes of this solicitation, the WCB hereby establishes an overall goal of 30% for MWBE participation, 15% for New York State-certified Minority-owned Business Enterprise (“MBE”) participation and 15% for New York State-certified Women-owned Business Enterprise (“WBE”) participation (based on the current availability of MBEs and WBEs). A contractor (“Contractor”) on any contract resulting from this procurement (“Contract”) must document its good faith efforts to provide meaningful participation by MWBEs as subcontractors and suppliers in the performance of the Contract. To that end, by submitting a response to this RFP, the respondent agrees that the WCB may withhold

Bidders who are only bidding on Service Lot #2 will need to submit a “Request for Waiver” form; the Board will provide the form to Bidders who are issued an award for Lot #2 only. Bidders bidding solely on Lot #2 do not need to submit a completed Attachment G - SDVOB 100 Utilization Plan Attachment or H - MWBE 100G Minority and Women-Owned Business Utilization Plan; rather, such Bidders should include a statement in their Administrative Volume (Volume I) stating that the Bidder is only submitting a bid for Lot #2, that Bidder is prohibited from subcontracting the services under Lot#2 and, therefore, Bidder will be submitting a “Request for Waiver” form, requesting a waiver from the MWBE and SDVB goals set forth in Sections 2.2.15 and 2.2.16 of the TPA-RFP.



payment pursuant to any Contract awarded as a result of this RFP pending receipt of the required MWBE documentation. However, the RFP also states: “Contractor(s) shall be responsible for performing the B/RB services exclusively, without the use of subcontractors. Subcontracting of the B/RB services will not be permitted.” Our question is: If subcontractors cannot be used for “B/RB services”, then how does the Contractor meet the MWBE goal? Does the MWBE goal not apply to the Service Lot #2, B/RB Services?

2.

4.5 Cost Volume, 4.5.2 Cost Component, B. Service Lot #2, page 53

The RFP requests pricing for a “single medical bill” and a “single medical reimbursement request” (see below). B. Service Lot # 2 Pricing for all B/RB Rev service shall be quoted as a cost “per bill” and/or “per reimbursement request” (depending upon whether contractor is performing direct bill review services

Health care provider bills received by one of the WCB’s Funds are expected to contain proper identifying information; ICD-10 codes; narrative, operative, or other report information as appropriate; and pricing in accordance with the medical fee schedule. Board forms used by health care providers are viewable here: http://www.wcb.ny.gov/content/main/forms/Forms_HEALTH_PROVIDER.jsp Medical reimbursement requests are made by insurers who are entitled to reimbursement from the Special Disability Fund. The requests are compiled on a Board Form and spreadsheet, viewable here:

http://www.wcb.ny.gov/content/main/forms/Forms_HEALTH_PROVIDER.jsp



or review of billing reimbursement requests for the SDF). Accordingly, Contractor’s cost proposal shall include: 1. A definition regarding what constitutes a single medical bill and a single medical reimbursement request; and 2. A price quote for each single medical bill or medical reimbursement request. Please explain the difference between these two items. For example, is the “single medical bill” the billing form submitted by the medical provider and the “medical reimbursement request” the reimbursement requests for medical bills that had already been paid by the employer or its workers’ compensation coverage? If so, please describe which form(s) are used for each item.

http://www.wcb.ny.gov/content/main/WAMO/wcl-14-6and15-8-reimbursement.jsp Bills and Explanations of Benefits are attached to such form and spreadsheet.

3. General

What is the total annual medical bill volume for Service Lot #2. Please provide a break down by medical bill submitted by the medical providers versus the reimbursement requests for

The total annual medical bill review volume for Service Lost #2 will vary depending upon how many Funds and claims the WCB decides to seek bill review services for, how many bills the winning bidder will be able to provide review for, and the cost of the bill review service.

http://www.wcb.ny.gov/content/main/WAMO/wcl-14-6and15-8-reimbursement.jsp




medical bills that had already been paid by the employer or its workers’ compensation coverage.

4. 3.1 1 Must Bidder hold an Independent Adjuster's License from DFS?

Bidder’s bidding on Service Lot #1 must: • be authorized to do business in NYS; • be a qualified Third-Party Administrator holding a valid WCB issued

license to represent insurance carriers; • possesses a minimum of five (5) years of experience administering

workers’ compensation claims governed by New York State Workers’ Compensation Law, and such services must have been delivered within the past five years;

• currently administer New York State workers’ compensation claims; and

• maintain at least one office in New York State. Bidder’s bidding on Service Lot #2 must:

• be authorized to do business in NYS; • possesses a minimum of five (5) years of experience delivering

services in New York State that are similar in scope to the services described in this RFP, and such services must have been delivered within the past five years.

Any additional licensing and experience possessed by the Bidder may be considered during the scoring of the technical proposals.

5. 3.2.2-13 and 3.4-54

Must "Professional Adjusters/Claims Examiners" hold a Workers Compensation No Fault Adjusters License from DFS?

Claims examiners shall be trained professionals with a minimum of one year of experience administering New York State Workers’ Compensation claims. Licensing and additional experience held by such trained professionals may be considered during the scoring of the technical proposals.



6. 4.5.2 and Pricing Sheet

Will transactional fees (fee per hearing; fee per activity check; fee per day of surveillance) be permitted in lieu of hourly billing?

No

7. 4.5.2 .3 Defense of Funds

Will partial in house services be permitted i.e. certain legal services but not all legal services in house, bill review in house but PPO discounting from subcontractor etc.?

Yes; the cost for Defense of Funds (as defined in RFP section 4.5.2.3) services, or portions thereof, to be performed in-house must be included in the Bidder’s proposed cost for the annual claims administration services fee. If Bidder wishes to have any or all of a Defense of Fund service performed by a subcontractor, Bidder must include an hourly rate for such service as part of its bid.

8. 4.5.2 Defense of Funds

DO MSA SERVICES INCLUDE RESPONSES TO CONDITIONAL PAYMENT NOTICES

No; however, the WCB expects that the Contractor will respond to all conditional payment notices, and the cost for such services must be included in the proposed claims administration fee.


Please indicate if the implementation/transition to the TPA will be completed in Stages? I.e. 1,500 claims on 7/1/18, 3,000 claims on 10/1/18 etc..

The implementation/transition to the TPA may be completed in stages if the WCB determines that staggered transitioning is necessary. Otherwise, the transfer of files may occur as a singular event.


If we include defense of funds in fee and use subcontractors/vendors for IME investigation etc. must they complete workforce utilization forms?

Yes – if Contractor enters into subcontracts with vendors for the purpose of fulfilling service obligations under a contract resulting from this RFP.

11. 3.5.2 Billing Procedures and Guidelines

In the RFP it indicates that billing is on a quarterly basis in arrears. Can billing be moved to a monthly basis in arrears?

No


Who is responsible for generating and issuing 1099's to medical providers? The TPA or the WCB?

The Contractor is responsible for generating 1099’s to health care providers for any payments made by Contractor.



13. General For Service Lot #2, will there be a panel of vendors selected? The WCB anticipates making a single award for Service Lot #2.

14. 1.2, Summary of Scope of Services

Please provide the following information, as it pertains to Service Lot #2: · Average annual bill volume · Expected annual increase in bill volume (if applicable)

Please see the response to # 3

15.

3.2.1, Conversion Services, question 1.k.

Regarding this clause: “where medical review is performed ‘in-house',” is there a current platform that the NYS WCB uses, and if so, what technology service is utilized?

The reference to medical review performed “in-house” in the referenced section, is for the purpose of distinguishing whether the bidder will need to be able to permit bill review using ICD-10 codes. If the bidder does not intend to perform bill review in-house (for Service Lot #1), bidder’s ES (record-keeping and reporting electronic claims system and/or bill/reimbursement request review system) will not need to have that capability. For information regarding the definition of “in-house” please refer to RFP section 4.5.2 and 4.5.2(A)(3).

16.

3.2.2, Administration Services, question 22.

Regarding this sentence: "Contractor shall also prepare and file all legally mandated reports and tax documents, including, but not limited to, those required by the Center for Medicare Services, the Health Care Reform Act, the Internal Revenue Service, and the Office of Foreign Asset Control," we are looking for more clarity regarding reporting mandates. Does the NYS WCB intend to outsource these reporting requirements?

This requirement pertains only to reporting requirements for claims arising under the Funds in Service Lot #1 (or where relevant, pertaining to bill review performed under Service Lot #2) that have been transferred to the successful Bidder(s) for claims administration.

17. General - Service Lot 2

Please indicate the annual number of bills submitted for review. Please see the response to #3




Please indicate how the medical bills will be submitted for review (electronic, manually or both).

Medical bills may be submitted electronically or manually.


What annual number of medical bills will be submitted for review manually? Please see the response to #3


Will the Service Lot # 2 contractor be communicating with multiple TPA's providing service under Service Lot #1?

This may be required; please see RFP section 3.2.2(26).


If only bidding on Service Lot #2 (Bill Review), is there a requirement to provide evidence of being a licensed TPA?

No, the Bidder eligibility requirements for Service Lot #2 do not require the Bidder to be a licensed TPA.


What is the estimated contract value for Service Lot 2? Please see the response to #3

23. 2.2.15

Please clarify this requirement as it is direct conflict with the prohibition on the use of subcontractors in Service Lot #2.

Please see the response to #1

24. 1.3

Would the WCB consider a five (5) year base term and two (2) - one (1) year options upon mutual agreement of the parties?

No

25. 3.3 (31) (47)

Would the WCB consider adding excused events language such that service level failures will be excused when (i) changes in scope, direction, budget, program processes or program funding are made at WCB request and such changes impact Contractor’s ability to perform in

No



accordance with the service levels; (ii) stated assumptions on which a performance goal is based turns out not to have been correct; or (iii) when a failure is due to the acts or omissions of the WCB or third parties outside of Contractor’s reasonable control. A single failure event will only result in the imposition of one service level credit.

26. 6.20 (E) Would the WCB willing to negotiate credit or chargeback amounts?

To the extent that performance penalties, such as credits or chargebacks, are applicable and not quantified by the Board in the TPA-RFP, the amount of such performance penalties will be determined by the parties. In instances where the amount of the performance penalty is specified in the TPA-RFP, it is solely within the Board’s discretion to modify the amount of the performance penalty downward.

27. 6.21

The Bidder respectfully requests a cap on liability consistent with industry standards and reasonable apportionment of risk on programs of similar size and complexity. Such a cap will have a positive effect on pricing for the WCB. Would the WCB consider limiting liability to the amount paid to Contractor in the preceding 12 months?

The Board is unwilling to place limits on the liability addressed in Paragraphs 2 or 3 of Section 6.21 of the TPA-RFP, “Indemnification and Limitation of Liability.” Paragraph 4 of Section 6.21 limits liability “[f]or all other claims against Contractor where liability is not otherwise set forth in the Contract as being “without limitation,” and regardless of the basis on which the claim is made, Contractor’s liability under the Contract shall be limited to the greater of the following: (i) $1,000,000 (ONE MILLION DOLLARS); or (ii) two (2) times the amounts paid to the Contractor under the Contract during the twelve months of the contract term which precedes the giving of notice of the claim by the State.



If the Bidder takes exception to any of the provisions of Section 6.21, “Indemnification and Limitation of Liability,” as set forth in the RFP, the Bidder should indicate such exception(s) in its proposal by following the procedures set forth in Section 2.2.11, Extraneous Terms. The WCB will entertain proposed changes to Section 6.21 during contract negotiations; however, it should be noted that NYS does have minimum standards for “Indemnification and Limitation of Liability.”

28. 6.24 (A)

Would the WCB agree to compensate Vendor for any unamortized costs and reasonable wind-down costs in the event of a termination for convenience or non-appropriation?

No

29. 6.30

Would the WCB consider minor changes to the insurance provisions for conformance with Contractor's standard policies and several clarifications to the requirements that can be discuss upon contract award?

If the Bidder takes exception to any of the provisions of Section 6.30, “Insurance,” as set forth in the RFP, the Bidder should indicate such exception(s) in its proposal by following the procedures set forth in Section 2.2.11, Extraneous Terms. The WCB will entertain proposed changes to Section 6.30 during contract negotiations; however, it should be noted that NYS does have minimum standards for “Insurance.”

30. 6.33 (A) (B)

Would the WCB consider limiting Contractor liability to damages directly resulting from Contractor’s own negligent acts or omissions?

If the Bidder takes exception to any of the provisions of Section 6.33, “Security, Non-Disclosure/Confidentiality, Press Releases,” as set forth in the RFP, the Bidder should indicate such exception(s) in its proposal by following the procedures set forth in Section 2.2.11, Extraneous Terms. The WCB will entertain proposed changes to Section 6.33 during contract negotiations; however, it should be noted that NYS does have minimum standards for “Security, Non-Disclosure/Confidentiality, Press Releases.”

31. 6.40

Would the WCB confirm that Contractor documentation do not include proprietary financial information or confidential personnel data?

Section 6.40, “Right to Inspect,” only applies to Contractor’s procedures, practices and controls related to the security of State data and information assets.



Upon request, Contractor will make available for review policies, procedures, practices and documentation related to the protection of State data and information assets, including but not limited to:

• information related to security governance; • network security, risk and compliance management policies and

procedures; • personnel security background screening/checks and vetting

procedures; • secure systems/software development protocols; • change/release management; • testing; • quality assurance; • vulnerability management; and • secure disposal/sanitization and documentation.

32. General

Would the WCB consider adding a provision that prohibits WCB from soliciting the employees of Contractor?

No

33. 3.5.2 Would the WCB consider a monthly bill cycle and a monthly payment cycle?


34. General Is this RFP a result of the expiration of existing contracts?

This RFP has been generated for the purposes as stated in RFP sections 1.1 and 1.2.

35. General Were there any service issues with current contractors?

The Board will not comment on the performance of vendors who have existing contracts with the Board for the provision of TPA services.

36. General How many contractors received this RFP?

The RFP is available on the Board’s website; the Board does not know how many vendors have accessed the RFP.

37. General What is the volume of open claims (including indemnity only and medical

Neither the WCB nor any of the present administrators of the various claims of these Funds have ever used the particular definitions of “open” and



only) in each fund (SIE, GSIT, UEF, SFRC, SFDB)?

“closed” specified in this RFP for the purpose of record-keeping or other measurements.

38. General Under Service Lot #2, what is the annual volume we can expect? Please see the response to # 3

39. 1.2

Would the WCB allow outsourcing for data entry of medical bills related to Service Lot #2? As long as all adjudication and review is done in-house.

The RFP does not permit such outsourcing; please see RFP sections 1.2 and 2.2.7.

40. 3.2.1

Would we be converting all legacy claims (opened and closed) for any or all of the funds? If so, for what funds and what is the volume of closed claims for each such fund?

The WCB presently intends to transfer all legacy claims. Please see the response to # 37.

41. 3.2.1 Besides general information about the employers, would any other policy data be converted, i.e. AR detail, etc.?

It is the WCB’s intention to provide as much information about claims transferred in accordance with the RFP as is available and possible in order to ensure the successful Bidder(s) will be able to effectively administer the claims. It is expected that all such information provided will be made a part of the successful Bidder(s) ES.

42. 3.2.1 Will any claims be paid ahead during any of the conversion period?

The WCB intends to work with the successful Bidder(s) to help ensure that there is no disruption in claims payments.

43. 3.2.2 Can you specify the number of bank accounts we potential would have to establish and maintain for each fund?

Contractor will be expected to maintain separate bank accounts for each type of Fund awarded; however, Contractor administering claims of defaulted Group Self-Insured Trusts and/or defaulted Self-Insured Employers will be expected to maintain separate bank accounts for each self-insured entity

44. General Is this RFP a result of the expiration of existing contracts? Please see the response to #34



45. 1.2 Summary of Scope of Services

How many total bills were processed in each of these respective areas (noted above) in the prior calendar year? What is the total bill charges processed for payment or reimbursement? What types of savings were achieved?


46.

2.2.15 Business Participation Opportunities for MWBE's

Do the 15% MBE, 15% WBE and 6% SDVOB requirements apply to the Bill Review Vendor if exclusively bidding on bill review?


47. 3.2 Service Requirements

Will the WCB allow the utilization of a recommendation of care PPO network and associated discounts? Could any other retrospective or prospective networks such as a DTN or PBM be utilized in the procurement?

For Service Lot #1, Contractor will be expected to perform any services that are necessary, proper, and legally permissible in the administration of claims. The Bidder’s Cost submission must be in accordance with the definitions supplied in RFP section 4.5.2. For Service Lot #2, subcontracting is not permitted. Please see RFP sections 1.2 and 2.2.7.


Will the TPA or the WCB be providing the Bill Review Vendor with claims data including compensable body part?

If the WCB opts to coordinate services between Service Lots #1 and 2 in accordance with RFP section 3.2.2(26), then the Contractor(s) under Service Lot #1 will be expected to provide such information.


What areas of business within the WCB could be awarded to the Bill Review Vendor? Defaulted Self-Insured Trusts or Employers, Uninsured Employers Fund, Special Funds 15-8, Special Funds 25-A or All of the above?

The successful Bidder for Service Lot #2 may be asked to provide bill review services for any of the claims that are the liability of Funds that are statutorily maintained by the WCB.




Will the Bill Review vendor be expected to interface via EDI with multiple TPA’s? Could you confirm if the interface would be an inbound claims feed file as well as an extract?

The Contractor may need to interface with multiple TPA’s, and the manner in which such communication is achieved will depend upon the type of record keeping and reporting electronic and/or bill/reimbursement review systems.


Will the Medical Bill Review vendor be able to assign and invoice for medical staff (RN or MD) to evaluate MG-2 or C-4Auth request in order to capture determinations within the software platform and apply to the medical bill review process?

The successful Bidder for Service Lot #2 will be expected to meet all of the service requirements of the RFP; and all costs associated with meeting such requirements must be included within the per bill or per reimbursement cost as per Bidder’s cost proposal. Please see RFP sections 1.2 and 2.2.7.


For 15-8 review of reimbursement requests, what documentation is the WCB looking for the Bill Review vendor to produce to verify? Could separate physician types / providers be broken into separate requests for reimbursement and processed accordingly?

The successful Bidder for Service Lot #2 may be expected to review reimbursement requests received by the Special Disability Fund. Such reimbursement requests will generally be in the format as provided here: http://www.wcb.ny.gov/content/main/WAMO/wcl-14-6and15-8-reimbursement.jsp The successful Bidder will be expected to provide the WCB with recommendations for proper payments, including explanations, as pursuant to the service and reporting requirements outlined in the RFP.


How many users would the WCB need to have access the medical bill review vendors online application?

The WCB anticipates that no more than 8 users would need to have access to the successful Bidder for Service Lot #2’s online application.





54. 4.5.2 Cost Component

Can pricing be presented both at a per bill rate as well as an incremental percentage of the cost savings for reductions below system driver application of the fee schedule including nurse review and expert biller and coder review?

Pricing must be presented in the manner dictated in section 4.5.2(B) of the RFP.

55. 6.20 (E) Would the WCB willing to negotiate credit or chargeback amounts? Please see the response to # 26.

56. 3.3 (39)

In regard to the contractor being directly responsible for up to 50% of the MG-2/C-4Auth would that include if the treatment would have been approved? Also, would the provider have to provide proof (fax confirmation, read receipt etc.) that they submitted the request to the proper place? The WCB will rule in favor of the provider if it is in E-case but no proof that it was sent to the TPA.

The successful Bidder(s) for Service Lot #1 may be responsible for up to 50% of a medical bill where such Bidder failed to provide a timely response to a properly filed MG-2 or C-4 Auth regardless of whether the treatment would have been approved. Exceptions to and the imposition of this penalty will be at the WCB’s discretion.

57. 3.4 (55)

Per the RFP an adjuster cannot be assigned more than 300 closed claims. Some GSITs and SIEs can have thousands of closed claims. Could this section be revised?

The Board is amending the RFP to remove the cap on the number of closed claims that a claims examiner/adjuster can be assigned. An amendment to the RFP amending the requirement, as set forth in this response, will be issued.

58. 3.2.1 Conversion Services, # j.

The data elements we are required to capture

The WCB will provide specific information about its reporting requirements to the successful Bidder(s)



59. 3.2.1 Conversion Services, # i.

The required data export format and elements

Reports will be expected in Excel or PDF form, and please see the response to # 58.

60. 3.4 Reporting Requirements, # 32.

The format and data elements for the required reports Please see the response to # 58

61.

3.2.2 Administration Services # 15 g.

The forms and letters that are required for claims administration Please see the response #58

62. 3.4 Reporting Requirements, # 44.

Phone tracking requirements for WTC volunteers Please see the response #58

63. General Where are the current staff located?

The staff presently administering the various claims of the Funds included in this RFP may be WCB employees, TPA employees, employees of the Special Funds Conservation Committee, and potentially employees of self-insured or group self-insured employers who may go into default at some future point. As such, staff involved in claims administration and bill review for these claims might currently be anywhere in or outside of New York State.

64. General Are the current staff available for possible roll over? Please see the answer to #63

65. General Is conversion going to need to take place from multiple sources?

Depending upon the volume of claims awarded to a successful Bidder, and which Funds such claims fall within, there may be a need to convert file information from multiple sources.

66. General Can we charge the file for our standard allocated expenses?

The cost proposal and billing must be in accordance with the RFP. Certain expenses that might be considered “standard allocated expenses” can permissibly be charge separate from the claims administration fee if the Bid was formatted to include such separate charges; however, certain other such expenses may not permissibly be charged separately. Please see RFP sections 3.5, 3.5.2, and 4.5.2 for additional information.



67. General Can we get a copy of current best practices for current adjusters and supervisors?

Please see the response to # 63

68. 3.5 Staffing Requirements, # 55

Are there review expectations on ‘closed’ files, since there is a cap of 300 per adjuster?

The WCB expects that the successful Bidder(s) for Service Lot #1 will provide claims administration services as required by the RFP. If a claim is designated closed in accordance with the definition contained within the RFP (see RFP section 3.5.1), it should be monitored as appropriate. In addition, the Board is amending the RFP to remove the cap on the number of closed claims that a claims examiner/adjuster can be assigned. An amendment to the RFP amending the requirement, as set forth in this response, will be issued.

69. General

What are the expectations with having a supervisor oversee 10 adjusters, 1,850 open files for a supervisor to oversee?

The WCB expects that the successful Bidder(s) for Service Lot #1 will provide claims administration services and fulfill all other requirements as pursuant to the RFP. The Board is amending the RFP to remove the cap on the number of open claims that a claims examiner/adjuster can be assigned. An amendment to the RFP amending the requirement, as set forth in this response, will be issued. Please see the response to # 101.

70. General Do we have an average for potential reopens?

The WCB is unable to forecast the number of claims that may reopen during the contract term.

71. General Are there any incentives for settling and/or closing files going forward?

Successful Bidder(s) for Service Lot #1 will be able to qualify for bonus/incentive payments. See RFP sections 3.3(40) and (41)

72. General They have mapped out a lot of penalties items for missteps, but what about the reverse incentives?

Please see the response to #71.

73. 3.3.1 Conversion Services

This section says 90 days for conversion; # 2 & 3 on chart says 30 days.

The conversion of records is a specific aspect of the overall conversion, and must be completed within 30 days as dictated by the RFP.

74. P 13 Confirm that MWBE goals, good faith efforts and plan are to be submitted online and with the proposal.

Bidders need to submit the following documents with their proposal:



• Attachment D - Minority and Women-Owned Business Enterprises – Equal Employment Opportunity Policy Statement;

• Attachment G - SDVOB 100 Utilization Plan; and • Attachment H - MWBE 100G Minority and Women-Owned Business

Utilization Plan. These documents should be completed and submitted to the Board as part of Bidder’s Administrative Volume (Volume 1). EXCEPTION: Bidders who are only bidding on Service Lot #2. Bidders who are only bidding on Service Lot #2 will need to submit a “Request for Waiver” form; the Board will provide the form to Bidders who are issued an award for Lot #2 only. Bidders bidding solely on Lot #2 do not need to submit a completed Attachment G - SDVOB 100 Utilization Plan Attachment or H - MWBE 100G Minority and Women-Owned Business Utilization Plan; rather, such Bidders should include a statement in their Administrative Volume (Volume I) stating that the Bidder is only submitting a bid for Lot #2, that Bidder is prohibited from subcontracting the services under Lot#2 and, therefore, Bidder will be submitting a “Request for Waiver” form, requesting a waiver from the MWBE and SDVB goals set forth in Sections 2.2.15 and 2.2.16 of the TPA-RFP.

75. General Will the assumed claims specifically be excluded from Payor Compliance performance metrics?

Successful Bidder(s) for Service Lot #1 will be expected to comply with all statutory, regulatory, and WCB requirements.

76. General What is the service expectation on closed claims? Please see the response to #68

77. 3.4 Reporting Requirements

What is the mechanism to report claims? How is it presently conducted Reporting requirements are contained in RFP section 3.3.



78. General What is the present turn-around time from funding request to receipt of funds?

Per RFP section 3.2.2(19), the WCB anticipates requiring 3 business days between the funding request and the receipt of funds.

79. General

Present administration is with various TPA’s. Is the bill review and payment history going to be made available for conversion?


80. General

How are issues caused by prior admin handling approached from performance guarantee / penalty standpoint (i.e. Orders of Chair)

The WCB does not intend to hold successful Bidder(s) for Service Lot #1 responsible for penalty issues that were clearly caused by a prior administrator, or which were caused by actions that predate the Bidder(s) provision of claims administration services.

81. General

If MG2 or C4 auth response untimely due to issue of outside contractor control (sent to wrong address/fax by provider) and Order of Chair issued, is contractor subject to penalty?

The WCB does not intend to hold successful Bidder(s) for Service Lot #1 responsible for such untimely responses where the initial request was improperly transmitted.

82. General Is there a rebuttal process for penalties assessed/audit results?

The WCB may consider objections to the penalties created within the RFP on a case by case basis.

83. General Can the Board provide data on $$ amount assessed in penalties against current admins?


84. General What is authority level (reserve/ payment/settlement)?

The WCB will provide various settlement considerations and parameters for successful Bidder(s) to review.

85. General Claim review requirement? If so, frequency of same. Please see the response to #68

86. 3.3.2, Administrative Services, # 14d

Can we use our own vendor partners or is that directed by Board? Are charges for ancillary services subject to a Board approved fee schedule?

For Service Lot #1, Bidder may perform any services that are necessary, proper, and legally permissible in the administration of claims. The bidder’s Cost proposal must be in accordance with the definitions supplied in RFP section 4.5.2. Also, please see the response to #66.



87. 3.3 Reporting Requirements, # 32

Reserve audit - If deemed unsatisfactory Contractor to reimburse cost of audit - what is considered unsatisfactory? What are parameters?

It will remain within the WCB’s discretion to determine whether audit results are satisfactory.


Notification to board of claims related penalty payments 2 days in advance or subject to 10% penalty of such payment even if payment is timely. What if any delay experienced is unrelated to contractor?

The WCB does not intend to hold successful Bidder(s) for Service Lot #1 responsible for delays that are caused by circumstances entirely beyond the control of the Bidder(s).

89. General

Do we not have the typical role of determining compensability as that is established by the State prior to referring the claim to us?

The WCB expects that the majority of claims transferred under this RFP will already have been established as compensable; however, there may be instances where the successful Bidder(s) for Service Lot #1 will be required to handle a claim or claims from inception.

90. General

Clarification/procedural details on arrangement with uninsured employers and funding arrangements overall to confirm our current processes can handle or what modifications would be needed (also need specific escrow replenishment reporting requirements on item 19 page 26).

The successful Bidder(s) for administration of claims arising within the Uninsured Employers’ Fund will not be required to seek payment or repayment from employers. The WCB intends to fund check runs as needed by Bidder to satisfy indemnity and medical claims payments.

91. General

Contemplate the Client Services need for this scenario. Will probably differ significantly from typical client relationships; we’ll definitely need a clear relationship owner and we need to clearly establish and document procedures up front. We can’t rely on




establishing procedures via emails and verbal communication – this program represents numerous exception processes. Where we deviate from our SOPs we need documented process and controls.

92. General Will the prior TPA data include EDI submission history? Please see the response to #41

93. General

Please confirm what information will be provided to establish files in our system including data fields provided and method of data transfer.


94. 3.2.1 Conversion Services

If specific files or reports are needed please provide examples of each.

The WCB intends to provide specific reporting requirements and formats to the successful Bidder(s). The information that will be requested, and the frequency at which such information will need to be provided are contained in RFP section 3.3.

95. 3.3 Service Requirements. j.

Please provide specifics on any known non-standard data fields that will be required.


96. 3.3 Service Requirements. 0.

If the Board has specific mandatory requirements beyond alerts incorporated into the claim system to enhance management of daily adjuster responsibilities such as reminders around payments and data quality audit items please provide.

The record-keeping and reporting electronic claims system requirements are outlined in RFP section 3.2.1.

97. 3.3.2 Administration Services, # 17

Please confirm that this is limited to data being captured at the time of the request.

The WCB expects that the successful Bidder(s) will keep up-to-date records of all of the information in RFP section 3.3.2(17) to the extent that such information is available for a particular case.




Please further define “in the format requested”.

The WCB expects that the successful Bidder(s) will respond to Board inquiries by providing a timely and accurate recitation of the information requested. If the information is requested on a spreadsheet, e-mail, return phone call, etc.; the information should be provided by spreadsheet, e-mail, return phone call, etc., respectively.


If the Board specified parameters go beyond production of loss runs that are consumed regularly by Insureds, Brokers, Carriers and many others and which are considered to be industry standard format, please expand on specific requirements.


100. Statewide Financial System 3.5

Not included with RFP? The WCB expects the successful Bidder(s) to comply with the requirements of the Statewide Financial System. Please see RFP section 3.2.2(19).

101. 3.4.55.

Would you consider waiving the claims administration limitations of 185 claims for open claims, especially as you are requesting different pricing models based on the age of the claims? If there is a limit for open claims, then there will not be any opportunities for our firm to provide discounted pricing based on the age and complexities of certain claims.

The Board is amending the RFP to remove the caps on the number of opened claims that a claims examiner/adjuster can be assigned. However, the contractor must ensure that adequate staffing is maintained to perform all necessary claims administration services and fulfill all other requirements pursuant to the RFP.

102. 3.4.55.

Would you consider waiving the claims administration limitations of 300 claims for closed claims? We feel this would not be necessary as we reassign adjuster's open claims as needed

Please see response to #57



when claims reopen. We typically do not assign closed claim counts to adjusters.

103. 3.5.2.1.

Would you consider invoicing monthly or payment at the beginning of a period? If payments are to be made in arrears, there may be a significant resulting cash flow problem if invoicing is performed in arrears.


104. 1.1.5 What volume of Disability claims inventory do you have today?

The WCB currently has less than 100 DB claims being administered by a third-party administrator.

105. 1.1.5

If DBL claims are taken over during the term of this contract period, would the claims be subject to the statutory limits (26 weeks) or would any enhanced benefit formerly offered by the employer/employee contracts still apply?

These claims are subject to the statutory limits.

106. 3.6

What form or financial assurance are you expecting from your contractor? A specific bond type? Commercial Crime coverage?

This will be determined at the WCB’s discretion during contract negotiations.

107. 3.5.1.5.

Under the definition of a "closed claim", a claim is considered permanently closed when a claimant dies. Is the chosen contractor expected to periodically check the death database against our inventory of "closed" claims (definition 3.5.1.2.)?

The WCB would not expect or require such checks of closed claims unless or until an event occurs that might cause such claim to re-open.



108. 1.1.5 Who is/are the current TPA(s) for Disability Claims?

The purpose of the Q&A process is to allow vendors to ask questions and seek clarification about the contents of the RFP to enable vendors to appropriately respond to the RFP. Accordingly, the Board will not provide the identity of vendors who have existing contracts with the Board for the provision of TPA services as such information is irrelevant to the preparation of a proposal in response to this RFP.

109. 6.12

Please clarify your desire for the TPA's "subcontractors" to be under a contract approved by the Board. Are you requiring every one of our legal vendors, IME vendors, surveillance firms, MSA vendors, etc., all be under a specific subcontract meeting the requirements of this section?

The requirements of Section 6.12 apply to contracts entered into by Contractor for the purpose of fulfilling service obligations under a contract resulting from this RFP.

110. Attachment C- Forms and Information

Please confirm that Contractor Disclosure Form A and B are not required to be completed with the bid proposal.

Contractor Disclosure Forms A and B do not need to be submitted with the Bid Proposal.

111. 6.3.4.

The data breach and cyber liability requirements are based on severity rankings as defined in the NYS Information Security Standard document No. NYS-S14-002. In that document, the information classification categories are defined based on a limited impact, serious impact, or severe/catastrophic impact, which in turn are defined on page 2 of the document. For the records contained under this contract, would

Moderate Risk



you consider the impact of a breach or unauthorized access to be considered limited impact, serious impact, or severe/catastrophic impact? In other words, would you consider a breach of this data to be low, moderate or high risk?

112. Attachments G, H, I

Please Clarify: would you like these forms completed in the bid package? Where would you like them to be included? (Which Volume?)

Yes; Attachment G - SDVOB 100 Utilization Plan, Attachment H - MWBE 100G Minority and Women-Owned Business Utilization Plan and Attachment I - EEO 100G Equal Employment Opportunity Staffing Plan need to be completed and submitted to the Board as part of Bidder’s Administrative Volume (Volume 1).

113. 4.5.2.4.

You state that all assessments and penalties will be reimbursed to the contractor. Does this include penalties that have been issued due to the fault of the contractor?

No; the Board is amending the RFP to revise the following sentence: “[a]ssessments under WCL § 142(5) and other assessments and penalties shall not be considered filing fees,” to add the words “or incidental” after the word “filing.” An amendment to the RFP amending the requirement, as set forth in this response, will be issued.

Documents

RFP Section Question Response - wcb.ny.gov · Contractor’s cost proposal shall include: 1. A definition regarding what constitutes a single medical bill and a single ... TPA. RFP