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Evaluation Tool
Evaluation Tool
Evaluation Tool
Evaluation Tool
Evaluation Tool
Evaluation Tool
Evaluation Tool
Evaluation Tool
Evaluation Tool
Evaluation Tool
Evaluation Tool
Evaluation Tool
Evaluation Tool
Evaluation Tool
Evaluation Tool
Evaluation Tool
Evaluation Tool
Evaluation Tool
Evaluation Tool
Evaluation Tool
Evaluation Tool
Evaluation Tool
Evaluation Tool
Evaluation Tool
Evaluation Tool
Evaluation Tool
Evaluation Tool
Evaluation Tool
Evaluation Tool
Evaluation Tool
Evaluation Tool
Evaluation Tool
Evaluation Tool
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Evaluation Tool

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  • 1. MississippiCAN Program RFP #20090127 Checklist for Completeness and Qualification of Offerors RFP Section Statement/Question Reference/Comment Y/N 1.3 Organizations Eligible to Offeror has not been sanctioned by a state or federal Section 1.3 Submit Proposals government within the last 10 years. Organizations Eligible (Documentation for each To Submit Proposals requirement) Offeror must have experience in contractual services Section 5.4.3 providing the type of services described in this RFP. Corporate Experience Offeror must be able to provide each required component Section 5.2 and deliverable as detailed in the Scope of Work. Transmittal Letter Offeror must have at least 5 years of Medicaid experience Section 5.4.3 Corporate Experience 4.2 Qualification of Offeror Each corporation shall report its corporate charter number in Section 5.2 its transmittal letter or have attached to the transmittal letters Transmittal Letter reasons for exemption. All corporations shall be in full compliance with all MS laws Section 5.2 regarding corporation or formation of and doing business in Transmittal Letter 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 Section 5.2 in the process of obtaining a license from to be effective Transmittal Letter 10/1/09, and be licensed in another state. 4.3.2 Proposal Submission Proposals must be submitted with components of the RFP Document Inspection Requirements clearly tabbed. An original and ten copies of the proposal under sealed Document Inspection cover must be received by DOM no later than 5:00 p.m. CST on March 16, 2009. Proposals should be delivered to Melanie Wakeland Document Inspection 4.4.7 Rejection of Proposals Does the proposal contain unauthorized amendments to the Section 5.2 RFP requirements? Transmittal Letter Is the proposal conditional? Section 5.2 Transmittal Letter Is the proposal complete? Document Inspection Has an authorized representative signed the proposal? Section 5.2 Transmittal Letter Does the proposal contain false or misleading information?
  • 2. MississippiCAN Program RFP# 20090127 Office of the Governor – Division of Medicaid Does the Offeror currently owe the state of MS money? 4.4.8 Alternate Proposals Is there only one proposal submitted by the Offeror, its Section 5.2 subsidiaries or related entities? Transmittal Letter 5.1 Introduction Does the technical proposal include a transmittal letter? Previously Noted Does the technical proposal include an executive summary? Previously Noted Does the technical proposal include a corporate background Previously Noted and experience? Does the technical proposal include a project organization Previously Noted and staffing plan? Does the technical proposal include methodology and a Previously Noted work statement? Does the technical proposal include project management Previously Noted and control? Does the technical proposal include a work plan and work Previously Noted schedule? 5.2 Transmittal Letter Is the transmittal letter in the form of a standard business Section 5.2 letter on the letterhead of the proposing company? Transmittal Letter Is the transmittal letter signed by an individual authorized to Section 5.2 bind the Offeror? Transmittal Letter Does the transmittal letter identify all material and Section 5.2 enclosures being submitted in response to the RFP? Transmittal Letter Does the transmittal letter include a statement indicating that Section 5.2 the Offeror is a corporation or legal entity? Transmittal Letter Does the transmittal letter include a statement that the Section 5.2 Offeror is registered or will be registered to do business in Transmittal Letter 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 Section 5.2 license from the Department of Insurance or other state Transmittal Letter license and application for license in the state of MS? Does the transmittal letter include a statement that the Section 5.2 Contractor agrees that any lost or reduced federal matching Transmittal Letter 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 2
  • 3. MississippiCAN Program RFP# 20090127 Office of the Governor – Division of Medicaid Offeror’s Federal tax identification number? Transmittal Letter Does the transmittal letter include a statement that no Section 5.2 attempt has been made or will be made by the Offeror to Transmittal Letter induce any other person or firm to submit or not to submit a proposal? Does the transmittal letter include a statement of Affirmative Section 5.2 Action that the Offeror does not discriminate in its Transmittal Letter 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 Section 5.2 or pricing information has been included in this letter or any Transmittal Letter other part of the technical proposal? Does the transmittal letter include a statement identifying all Section 5.2 amendments to this RFP issued by DOM which have been Transmittal Letter 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 Section 5.2 Offeror has read, understands and agrees to all provisions Transmittal Letter of this RFP without reservation? Does the transmittal letter include a certification that the Section 5.2 Offeror’s offer will be firm and binding for 180 days from the Transmittal Letter proposal due date? Does the transmittal letter include a statement naming any Section 5.2 outside firms responsible for writing the proposal? Transmittal Letter Does the transmittal letter include a statement agreeing that Section 5.2 the Contractor and all subcontractors will sign the Drug Free Transmittal Letter Workplace Certificate (Exhibit 1)? Does the transmittal letter include a statement that the Section 5.2 Offeror has included the signed DHHS Certification Transmittal Letter 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 Section 5.2 proposals submitted by corporations must contain Transmittal Letter 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 3
  • 4. MississippiCAN Program RFP# 20090127 Office of the Governor – Division of Medicaid proposal? Does the transmittal letter include a statement that Section 5.2 proposals submitted include a statement that the Offeror Transmittal Letter 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 Section 5.2 proposal deviates from the detailed specifications and Transmittal Letter requirements of the RFP, the transmittal letter explains these deviations? 4
  • 5. MississippiCAN Program RFP# 20090127 Office of the Governor – Division of Medicaid MississippiCAN Program RFP #20090127 Evaluation 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: 100 5.3 1. Does the Executive Summary condense and highlight the contents Executive of the Technical Proposal in such a way as to provide a broad 5 Summary understanding of the entire proposal? 2. Does the Executive Summary include a clear statement of the 15 Offeror’s understanding of purpose and goals? 3. Does the executive Summary include a narrative description of the 10 proposed effort, items to be delivered, and services to be provided? 4. Does the Executive Summary include a description of the Offeror’s 15 coordinated care plan delivery system? 5. Does the Executive Summary include a brief description of the 20 Offeror’s qualification with the Offeror’s key strengths highlighted? 6. Does the Executive Summary include a description of the Offeror’s 15 experience and familiarity with the medical, educational, social, and economic needs of the population to be served? 7. Does the Executive Summary include a description of the Offeror’s 20 ability to further the Division’s goals for this program? 8. Is the Executive Summary more than four single-spaced typed If Summary is over long, Minus 10 points pages in length? reduce number of points awarded in this section Maximum Possible Points for Corporate Background: 70 Points 5.4 1. Does the Corporate background include information about all Preferred response includes 14 Corporate current and recent Medicaid and related projects dating back to at Medicaid coordinated care Background least January 2004 and through the present? experience with target populations or equivalent in What are they? more than one other site and for more than 5 years. 5
  • 6. MississippiCAN Program RFP# 20090127 Office of the Governor – Division of Medicaid 2. Does the corporate background include the date the corporation 2 was established? What is it? 3. Does the corporate background include the principal place of 2 business? Where is it? 4. Does the corporate background include the location of the Response must include 5 proposed administrative offices for this project? administrative office in Jackson. Where is it? 5. Does the corporate background include the description of 2 Ownership? What is it? 6. Does the corporate background include experience in systems Preferred response includes 12 capabilities to collect, report and monitor quality and operational more than 5 years experience indicators? serving more than one program. How many years of experience? 7. Does the corporate background include total number of staff Preferred response will 9 dedicated to administering MississippiCAN? include key positions as described in the RFP and How many are there and in what categories? dedicated staff for provider recruitment/relations. 8. Does the corporate background include performance history and 6 reputation? What is it? 9. Does the corporate background include current products and Preferred response includes 9 services, in particular programs for healthy behaviors, wellness services specifically for the and disease management? targeted Medicaid populations. Programs that What are they? link to existing community resources and groups especially desirable. 10 Does the corporate background include professional Preferred responses include 9 accreditations pertinent to the services provided in this RFP? NCQA accreditation at the 6
  • 7. MississippiCAN Program RFP# 20090127 Office of the Governor – Division of Medicaid Excellent level. What are they? 11 Does the corporate background include information on any If Offeror responds positively Minus 18 points contractual termination for cause within the past five (5) years? to this question, reduce What were they? number of points for this section by 14. Maximum Possible Points for Financial Soundness: 200 5.4.2 Financial 1. To reviewers: You are not asked to score this section of the RFP. Statements 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 1. Does the corporate experience section present the details of the Response addresses 20 Experience Offeror’s experience with the scope of work required by this RFP? Medicaid specific experience at a minimum and preferred What is the experience? response includes experience with targeted populations. 2. Does the corporate experience show their last five (5) years of 8 Medicaid experience presented chronologically? What is it? 3. Does the corporate experience provide a list of at least the last Reference checks to occur 42 three (3) most recent, relevant contracts to serve as corporate during evaluation and scoring references include the client’s name and address and the current will depend on the quality of telephone number of the client’s responsible project administrator references. 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 7
  • 8. MississippiCAN Program RFP# 20090127 Office of the Governor – Division of Medicaid What are they? Maximum Possible Points for Project Organization and Staffing: 110 5.5 1. Does the proposal include project team organization, charts of 20 Project proposed personnel and positions, and job descriptions of key Organization and management personnel? Staffing 2. Does the proposal include the following job descriptions? 30 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 3. Resumes for key staff positions. Does each resume include: Preferred response has the 60 • Experience working with Medicaid programs? key positions already filled • Experience working with coordinated care organizations? with staff that have prior • Relevant training and accreditation? Medicaid coordinated care • Experience in managing large-scale contractual service experience. projects? • Three references? 8
  • 9. MississippiCAN Program RFP# 20090127 Office of the Governor – Division of Medicaid MississippiCAN Program RFP #20090127 Evaluation Tool Section 5.6 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. 5.6 Methodology/Work Statement Award 1 - 5 Pts (1 being least # Statement/Question Response Elements effective, 5 being most effective) Benefits 1. Describe the approach you will take to Information on covered services is inform members about covered health • Included in new member materials services including covered pharmacy • Covered in new member welcome calls services. • Covered in periodic newsletters (Limit to three pages.) • 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 Re encouraging member to engage in wellness processes you will put in place to • Included in new member materials encourage members to engage in • Covered in new member welcome calls wellness programs including the approach • Covered in periodic newsletters you intend to use to ensure that members • Incorporated into community outreach receive a physical exam annually and activities appropriate intervention to ensure • Appropriate incentives offered e.g. discounts improved health outcomes. at gyms, discounts at weight reduction (Limit to two pages.) 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 9
  • 10. MississippiCAN Program RFP# 20090127 Office of the Governor – Division of Medicaid Award 1 - 5 Pts (1 being least # Statement/Question Response Elements effective, 5 being most effective) • Covered in new member welcome calls • 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 plan described, including collaboration with providers of mental • Meeting frequency health services in order to coordinate care • Attendees for members. • Likely agendas and issues to be addressed (Limit to two pages.) • Bidder’s similar experience elsewhere 4. Describe any benefits over and above the Over and above benefits should tie to required benefits that you propose to • Participation in wellness programs including provide to members. physical exams (Limit to two pages.) • Compliance with disease and case management programs 5. Describe the process you will have in Process to include place to ensure that any new member has • Communication with DOM to ensure prompt an appointment scheduled with the receipt of info on medical home selection selected medical home within at least 120 • Initial telephonic outreach with new member days of enrollment. calls • Method to identify when an appointment has not been scheduled • Targeted outreach and interventions Administrative 6. Describe your member call center • Hours of operation are 24/7 Services operations including: • Location: Mississippi location is ideal, • Location of operations (If out of domestic location strongly preferred. state, describe how it will • Minimum performance standards: accommodate services for 10
  • 11. MississippiCAN Program RFP# 20090127 Office of the Governor – Division of Medicaid Award 1 - 5 Pts (1 being least # Statement/Question Response Elements effective, 5 being most effective) Mississippi.) o Abandon rate less than or equal to • Standards for rates of response 5% (live answer, incomplete calls, o Service level – 85% of calls answered speed of answer, average length within 30 seconds of call, etc.) and measures to o Speed of answer – 30 seconds ensure standards are met • If automated call answering for frequent • Accommodations for non-English questions, response describes questions speaking, hearing impaired, and handled automatically and options for over- visually impaired callers ride. • Staffing ratios including number of • Re language capabilities, staff should include call center employees per enrolled bi-lingual Spanish and Vietnamese speaking member and supervisor to staff staff ratio • Staffing ratios: • Describe the process in place to o Description of employee per member insure that member calls staffing ratio and rationale. pertaining to immediate medical o 10 employees per supervisor needs are properly handled. • Immediate medical needs calls transferred to • Training program for call center decision making clinician within 1 hour. employees including, but not • Well established and described training limited to, cultural competency program, including cultural competency. (Limit to four pages.) 7. Describe the informational materials you • Credible materials described and presented in propose to send to new members. mock up form. Address language alternatives that will be • Reading level addressed available and how you will ensure that reading levels will be at a sixth grade level. (Limit to two pages, excluding copies of materials.) 8. Describe your process to produce and • Credible process described. distribute identification cards and member • Response includes actions CCO will take information to members within 10 when the address of record is inaccurate. business days of enrollment. (Limit to two pages.) 9. Describe your provider call center • Hours of operation are 9-5 M-F operations including: • Location: Mississippi location is ideal, 11
  • 12. MississippiCAN Program RFP# 20090127 Office of the Governor – Division of Medicaid Award 1 - 5 Pts (1 being least # Statement/Question Response Elements effective, 5 being most effective) • Hours of operation domestic location strongly preferred. • Location of operations (If out of • Minimum performance standards: state, describe how it will o Abandon rate less than or equal to accommodate services for 5% Mississippi.) o Service level – 85% of calls answered • Standards for rates of response within 30 seconds (live answer, incomplete calls, o Speed of answer – 30 seconds speed of answer, average length • Credible description of job qualifications of call, etc.) and measures to • Staffing ratios: ensure standards are met o Description of employee per member • Job qualifications for call center staffing ratio and rationale. employees o 10 employees per supervisor • Staffing ratios including number of • Well established and described training call center employees per enrolled program, including cultural competency. member and supervisor to staff • Automated call answering for frequent ratio questions desired; response describes • Training program for call center questions handled automatically and options employees including cultural for over-ride. competency • Web based mechanism to answer frequent • The extent to which you plan to questions, especially related to claims use electronic means of payment desired; response describes communication to respond to questions handled and documentation. provider inquiries and how you propose to do so (Limit to three pages.) 10. Provide a general Management • Full response to question includes Information System (MIS) description o Systems diagram including: o Description of components and other • A systems diagram that describes system interfaces including each component of the  Workflow management management information system  Enrollment and all other systems that  Benefits administration interface with or support it  Provider data base • How each component will support  Fee schedules the major functional areas of the  Claims adjudication MississippiCan program  Fee for service and capitation 12
  • 13. MississippiCAN Program RFP# 20090127 Office of the Governor – Division of Medicaid Award 1 - 5 Pts (1 being least # Statement/Question Response Elements effective, 5 being most effective) (Limit to 10 pages, including diagram.) payments  Care and utilization 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 • Desired response is that no modifications or (MIS) that will be necessary to meet the updates are required. requirements of this program and your • If modifications or updates required, they plan for their completion. should be minor and NOT in areas of (Limit to four pages.) enrollment or claims payment. 12. Describe your claims processing • Claims processing system should be a operations including: recognized system with a demonstrated track • The claims processing systems record e.g. TBD that will support this program • Standards meet or exceed the following: • Standards for speed and accuracy of processing and measures to o Claims Adjudication - The ensure that standards are better Contractor must properly adjudicate or no less than Medicaid fee-for- 90 percent of all clean claims service program within 30 calendar days of receipt, (Limit to four pages.) 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. 13
  • 14. MississippiCAN Program RFP# 20090127 Office of the Governor – Division of Medicaid Award 1 - 5 Pts (1 being least # Statement/Question Response Elements effective, 5 being most effective) o Claims Adjudication - The 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 • Understanding that Medicaid is the payer of capturing third party resource and last resort payment information from your claims • Uses State third party resource fill as a system for use in reporting cost-avoided primary data source to update member other dollars and provider-reported savings to insurance data; updates to State third party DOM. Explain how you will use such resource files occur daily information. Describe the process you • Routine and periodic survey of membership use for retrospective post payment for other coverage recoveries of health-related insurance as • Claims processing automatically checks for well as your process for adjudicating other coverage with payments made claims involving third party coverage. assuming CCO is the secondary payer is (Limit to three pages.) 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 Re complete data complete encounter data is submitted • Response includes process to monitor data accurately and timely to DOM consistent submission from providers, including with the required formats. Include in your identification of outliers and interventions. 14
  • 15. MississippiCAN Program RFP# 20090127 Office of the Governor – Division of Medicaid Award 1 - 5 Pts (1 being least # Statement/Question Response Elements effective, 5 being most effective) response how you propose to monitor • CCO contracts with providers and data completeness and manage the non- subcontractors include encounter submission submission of encounter data by a requirements. provider or a subcontractor. Re accurate and complete submission (Limit to four pages.) • EDI process described and in compliance with Mississippi guidelines • Experience and performance in other locations described 15. Describe the capability your management Credible system and process described that will have to access a database of service includes information to create ad hoc reports for • The data warehouse, its libraries and data both Offeror management and DOM. stored in the libraries Include a description of the system and • Frequency of updates software, an overview of the data that will • The business intelligence unit that uses the be held, and the resources and capability data you will have to use large amounts of data • Software used to create ad hoc reports. • Ability to access subcontractor data (Limit to five pages and a list of • Experience in other settings anticipated reports.) • Examples of problems or issues identified or interventions monitored through use of this capability 16. Explain the process you will put in place to Response includes maintain your provider file with detailed • Process to gather information including information on each provider sufficient to o Annual frequency at a minimum support provider payment, meet all federal o Mode of data collection e.g., and DOM reporting requirements, and electronic, part of routine visits cross reference to state and federal o Process in special situations including identification numbers to ensure excluded at academic medical centers for providers are identified. residents and changes in staff at (Limit to two pages.) predictable times (July 1) • Process to cross walk data o Process to cross walk to federal ID numbers o Process to cross walk to state ID 15
  • 16. MississippiCAN Program RFP# 20090127 Office of the Governor – Division of Medicaid Award 1 - 5 Pts (1 being least # Statement/Question Response Elements effective, 5 being most effective) numbers • Process to contact/interact with providers when problems are identified 17. Describe the process you will use to utilize Response includes description of the eligibility and enrollment files from • Weekly automated enrollment file processing DOM to manage your membership. • Weekly exception/error processing Include the process for resolving • Manual processing/reconciliation for any discrepancies between these files and outstanding item including outreach to your internal membership records. members and communication with DOM (Limit to two pages.) • Weekly updated communications to providers and subcontractors 18. Describe the fraud and abuse program Dedicated unit should be described that that you will implement including: • Uses a plan that complies with the • Fraud detection methods that will guidelines be used • Integrates evaluation of claims data, • Steps that will be taken if fraud is billing patterns, and member complaints detected including DOM • Includes a training program for CCO staff notification on identifying fraud and abuse • 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.) 19. Describe your emergency response • Desired response includes both a short continuity of operations plan. Attach a summary and a full disaster recovery plan copy of your plan or, at a minimum, attached. summarize how your plan addresses the • Acceptable response includes a summary of following aspects of pandemic each of the elements described: preparedness and natural disaster o Employee training recovery: o Identified essential business functions • Employee training and key employees within your • Identified essential business organization necessary to carry them functions and key employees out within your organization o Contingency plans for covering 16
  • 17. MississippiCAN Program RFP# 20090127 Office of the Governor – Division of Medicaid Award 1 - 5 Pts (1 being least # Statement/Question Response Elements effective, 5 being most effective) necessary to carry them out essential business functions in the • Contingency plans for covering event key employees are essential business functions in the incapacitated or the primary event key employees are workplace is unavailable incapacitated or the primary o Communication with staff and workplace is unavailable suppliers when normal systems are • Communication with staff and unavailable suppliers when normal systems o Specifically address your plans to are unavailable ensure continuity of services to • Specifically address your plans to providers and members ensure continuity of services to o How your plan will be tested providers and members • How your plan will be tested (Limit to five pages.) 20. Describe how and where records will be Credible response described. maintained and the process and • Desired location is in Mississippi timeframe for retrieving records needed or • Desired timeframe is one week or less. requested by DOM or other State or external review representatives. (Limit to two pages.) 21. Describe your plans to establish an Credible approach described. 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) Provider 22. Describe your plan to ensure that your Adequate response will include the following by Network provider network meets the network and the CCO access requirements of the Program. • Compliance is measured annually Describe the method you plan to use on • Travel time is measured using GeoAccess an ongoing basis to assess and ensure • Appointment access is measured using on- that DOM’s network standards are site appointment log review and secret maintained, including standards related shopper calls to : • Cultural competency is measured using on- • Travel time site assessment • Appointment access • FQHC and RHC inclusion is measured by 17
  • 18. MississippiCAN Program RFP# 20090127 Office of the Governor – Division of Medicaid Award 1 - 5 Pts (1 being least # Statement/Question Response Elements effective, 5 being most effective) • Cultural competency assessing contracts in place vs. existing sites • After hours access • Annual review of necessary services as • Inclusion of FQHCs and RHCs contracts with out of state providers • Inclusion of out-of-state providers • Annual review of available non-hospital and for medically necessary services urgent care providers and contracts in place • Inclusion of non-hospital urgent and emergent care providers (Limit to eight pages.) 23. How do you use GeoAccess mapping to Rank responses based on number of providers in ensure network adequacy? Using each region to serve the targeted population. 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.) 24. Should your organization be unable to Credible response will include secure an agreement with a key provider • Single case agreements at the Medicaid rate type in a given geographic area, what or an enhanced rate locally strategies will you use to ensure that • An out of area provider with transportation members have access to care? support provided by the CCO (Limit to two pages.) 25. Describe any provider incentive programs At a minimum, incentives to you plan to implement in order to improve • Increase the number of MississippiCAN access. members (Limit to two pages.) • Extend hours of operation 26. Describe the approach you will take to Minimum response includes assess provider satisfaction including • Annual provider representative visits tools you plan to use, frequency of • Annual survey by Provider Relations/Services assessment, and responsible parties. unit (Limit to two pages.) • Discussions at Quality Assurance committee meetings • Periodic focus groups with physician office staff 27. Describe the mechanisms you will use to Mechanisms to include 18
  • 19. MississippiCAN Program RFP# 20090127 Office of the Governor – Division of Medicaid Award 1 - 5 Pts (1 being least # Statement/Question Response Elements effective, 5 being most effective) communicate with providers and the • Quarterly newsletters content you anticipate including in • Special issue “faxes” communications. • Stuffers with claims payments (Limit to three pages.) • E-mail communications Content to include • Medical standards • Special areas of health focus e.g. diabetes screening • Administrative issues 28. Explain your process for ensuring that Response includes providers are enrolled in Medicaid and • Cross walk of provider file against state file to have a valid identification number. identify any outliers (Limit to two pages.) • Provider network representative outreach to providers to confirm data, identify obstacles, and develop approach to overcome obstacle. 29. Please submit copies of your standard Legal to review contracts to ensure appropriate provider contracts. elements in place 30. Provide a listing by provider type/specialty Rank by number of signed letters of intent in of the providers from whom you have necessary specialties. received a signed letter of intent to participate in your provider network. Care 31. For members who have not selected a Assignment process response should address Management medical home within 30 days of • Geographic match enrollment, describe the process you will • Language/cultural match use to assign members to a medical home • Family member match within 60 days of enrollment. Describe • If available, health issue match how you will inform medical home Information process should address initial contact (primary care providers) of new members. and follow up contacts to ensure appointments. (Limit to three pages.) 32. Will your program require referrals from In general, responses should primary care providers in order to • Require referrals for most services but not authorize services from specialists? certain basic services such as ob-gyn Under what circumstances, if any, may a • Allow specialists to act as a PCP for chronic specialist be designated as a member’s medical conditions such as HIV primary care provider? (Limit to two pages.) 19
  • 20. MississippiCAN Program RFP# 20090127 Office of the Governor – Division of Medicaid Award 1 - 5 Pts (1 being least # Statement/Question Response Elements effective, 5 being most effective) 33. Describe the policies, procedures, and Responses should include processes you will use to conduct • Scanning of claims data to ensure age and outreach and follow up to ensure that sex appropriate preventive care services are members receive all recommended provided preventive and medically necessary • Scanning of claims data to ensure disease follow-up treatment. state appropriate services are provided. (Limit to two pages.) • 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 Clear and specific responses to each of the items case management, including how you will posed. case manage and what services you will • Responses should use claims and encounter provide. Address the following issues in data to identify case management situations. the response: • Case manager interactions should be • How will you identify potential multimedia, i.e. electronic, automated phone case management situations contact, personal phone contact. • If you use a list of diagnoses to • All interactions should be documented. identify cases for management • Approach should include disease/condition and if so provide the list specific initiatives e.g. lay outreach for • Once a case is identified, how you pregnancy. 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 20
  • 21. MississippiCAN Program RFP# 20090127 Office of the Governor – Division of Medicaid Award 1 - 5 Pts (1 being least # Statement/Question Response Elements effective, 5 being most effective) • Any software you use to identify 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 Clear and specific responses to each of the items processes you will use to provide disease posed. management for members with diabetes, • Responses should use claims and encounter asthma, hypertension, obesity, congestive data to identify disease management heart disease, hemophilia at a minimum. situations. Specifically address: • Interactions with members should be • Identification and outreach to multimedia, i.e. electronic, automated phone members requiring disease contact, personal phone contact. management services • All interactions should be documented. • Stratification (risk levels) and Approach should include disease specific member interventions you will implement identification, stratification, and interventions. 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.) 36. For members with special needs, describe • Member identification processes are the policies, procedures and processes described including referrals from DOM, you will put in place to ensure coordination internal Member Services, providers; of care across the care continuum. encounter and claims data; etc. Describe how you will assist members • Members are linked to a specific support with special needs in identifying and within the organization such as a case gaining access to community resources manager or EPSDT outreach worker who is 21
  • 22. MississippiCAN Program RFP# 20090127 Office of the Governor – Division of Medicaid Award 1 - 5 Pts (1 being least # Statement/Question Response Elements effective, 5 being most effective) that may provide services that the accountable for arranging for care Medicaid program does not cover. • CCO establishes a community resource (Limit to three pages.) “book” or equivalent and a program to maintain productive working relationships to facilitate gaining access to services. 37. Describe your approach to utilization • UM must be directly accountable to a management, including: physician. • Lines of accountability for • Description should be comprehensive, utilization policies and procedures including all departments that are involved • Data sources and processes to including pharmacy determine which services require • Use of objective, external guidelines e.g. prior authorization and how often Interqual, to guide decisions these requirements will be re- • Involvement of advisory groups to address evaluated issues of emerging technology • Process and resources used to • Ideally, prior authorization mirrors DOM’s prior develop utilization review criteria authorization requirements for Outpatient • Prior authorization processes for Physical, Occupational and Speech Therapy, members requiring services from Inpatient Acute Care, Durable Medical non-participating providers or for Equipment, Home Health, Private Duty members who require expedited Nursing and Organ Transplant. prior authorization • Method to ensure inter-rater reliability and • Processes to ensure consistent frequency of evaluation. application of criteria by individual clinical reviewers (Limit to six pages.) 38. Describe the policies and procedures you • Prospective and concurrent review processes will put in place to control avoidable are in place for all elective admissions hospitalization and hospital readmissions. • Discharge planning is comprehensive to avoid (Limit to two pages.) 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 22
  • 23. MississippiCAN Program RFP# 20090127 Office of the Governor – Division of Medicaid Award 1 - 5 Pts (1 being least # Statement/Question Response Elements effective, 5 being most effective) • Reference to disease state management and case management programs • Health and wellness initiative for members 39. What is your definition of medically • Ideal response uses the same definition used necessary care? Describe your process by MS DOM, below: for developing and periodically reviewing o Services or supplies that: are proper and revising the definition. Describe the and needed for the diagnosis or degree to which your definition is treatment of your medical condition, consistent with or differs from DOM’s are provided for the diagnosis, direct definition of medical necessity. (Limit to care, and treatment of your medical two pages) 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, Response should be multi-dimensional, policies, procedures, or initiatives you will addressing members, providers, and community put in place to avoid unnecessary factors emergency room utilization. • Members encouraged to establish relationship (Limit to three pages.) 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 management if appropriate 23
  • 24. MississippiCAN Program RFP# 20090127 Office of the Governor – Division of Medicaid Award 1 - 5 Pts (1 being least # Statement/Question Response Elements effective, 5 being most effective) • 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 • Claims for emergency services by non-par non-participating providers who provide providers are flagged for special handling. emergency services to members are paid • Claims are forwarded to medical management on a timely basis. Also describe your for prompt review and authorized for payment process to insure appropriate • Medical management assigns a staff member communication with the provider, follow- to outreach to the member and the provider to up communication with the members’ expedite transfer of information to the medical home, and follow-up care for the member’s medical home member. (Limit to two pages) • 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 • PBM has demonstrated experience Manager (PBM), describe the • Assignment of responsibilities is clear in the arrangement and include a copy of the contract; contract includes performance contractual agreement. standards and penalties if standards not met. (Limit to one page.) 43. Provide a copy of the Preferred Drug List • PDL included (PDL) you will utilize and describe the • The prior authorization process described is exception process if a non-preferred drug not overly cumbersome is used. • Emergency authorization process and (Limit to two pages.) response described 44. If applicable, explain who audits the PBM • Audit conducted by CCO or designee with and on what schedule. Are the audits experience in PBM auditing based on Mississippi state laws and • Mississippi audit standards preferred regulations or are audits based on the • Audits happen bi-annually requirements of the state of domicile? Are • Financial sanctions are in proportion to audit results reported and on what improper activities schedule? What sanctions are imposed if improper activities are detected? (Limit to two pages.) 45. Describe the rebate management program • General description of program and what’s 24
  • 25. MississippiCAN Program RFP# 20090127 Office of the Governor – Division of Medicaid Award 1 - 5 Pts (1 being least # Statement/Question Response Elements effective, 5 being most effective) you will put in place. Include the drugs to covered: brands and/or generics be included, formulas that will be used to • Contracts with manufacturers in place calculate rebates, dispute resolution. • Contracts specify drugs covered and formulas (Limit to three pages.) 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 • Concurrent review in place at point of service utilization program you will put in place. via clinical edits in claims payment system (Limit to three pages.) • Retrospective review of all drugs ordered and filled • Special reviews of high cost/high frequency drugs. 47. Describe how you will identify provider Response should integrate use of following utilization patterns to improve care and reports described elsewhere reduce costs. • Physician provider profiles, including ER use (Limit to two pages.) • Pharmacy drug utilization review reports • Data from preventable serious medical error investigations Response 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 • Routine claims review to identify members psychotropic drugs in order to assist in the taking psychotropic drugs coordination of care for members with • Outreach to providers to ensure resources mental health needs. 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 to mental health service providers as appropriate. 25
  • 26. MississippiCAN Program RFP# 20090127 Office of the Governor – Division of Medicaid Award 1 - 5 Pts (1 being least # Statement/Question Response Elements effective, 5 being most effective) 49. Describe the policies and procedures you • Use claims and member demographic data to will put in place to develop and maintain a identify topics by geographic area for focus. comprehensive health education program • Identifying existing community resources for members. Please address: which to work to develop most effective • Your rationale for selecting areas programs. of focus • Integrate health education with community • How you will ensure that reading events levels are at a sixth grade level • Include materials and programs to support • The language alternatives that will providers in educating members be available to non-English • Possibly include a member advisory group speakers/readers • Address reading levels and non-English • How visually impaired will be materials accommodated (Limit to four pages.) Quality 50. Provide an overview description of your • Quality assurance activities are under the Assurance proposed quality assurance program. direct responsibility of the Board. Include the following in your description: • Program is based on health status data • The lines of accountability for the obtainable within the Plan. program • Health services data, both within the plan and • How you will select areas of focus in the literature, is used to design the QA • How you will use evidence based program practices in developing your • Staff has appropriate qualifications: program quality assurance program is under the direction of a qualified physician • How you will use data to design with nurses and other health care and implement your quality professionals involved. assurance program • There is a clear separation between UM and • What staff will be assigned to this QA activities. program and their qualifications • How will you ensure separation of responsibilities between utilization management and quality assurance staff? (Limit to six pages.) 51. Describe the policies and procedures you • Claims based system to identify problem have in place to reduce health care cases e.g. inconsistent admission and associated infection, medical errors, discharge diagnoses 26
  • 27. MississippiCAN Program RFP# 20090127 Office of the Governor – Division of Medicaid Award 1 - 5 Pts (1 being least # Statement/Question Response Elements effective, 5 being most effective) preventable serious adverse events • Policy (consistent with CMS guidelines) not to (never events) and unnecessary and pay for services that are harmful, inferior ineffective performance in these areas. quality, medically unnecessary (Limit to two pages.) • 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 • Describes data warehouse and the various encounter data, trending and other ad hoc data elements included reports to systematically and objectively • Address the software used to analyze data monitor, measure, and evaluate the • Address staff in place to accomplish these quality and appropriateness of care and tasks services provided. Specify the reports • Describe the purposes for which the data will you propose to use. be used e.g. designing provider incentives, (Limit to four pages.) 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 • Process in place to monitor literature and cull place to notify providers of new practice data on new practice guidelines. guidelines and to monitor implementation • Newsletter/fax/other mechanisms in place to of those guidelines. communicate new practice guidelines (Limit to two pages.) • Data analysis allows immediate follow-up to assess implementation • Corrective action plans will be prepared as necessary. 54. Describe the policies, procedures, and • Describe providers for whom profiles are processes you will use to conduct provider prepared; at a minimum should include PCP profiling to assess the quality of care profiles, ideally should also include high delivered. volume providers (Limit to two pages.) • Describe source data for the reports • Describe report content and frequency; ideally 27
  • 28. MississippiCAN Program RFP# 20090127 Office of the Governor – Division of Medicaid Award 1 - 5 Pts (1 being least # Statement/Question Response Elements effective, 5 being most effective) 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 • Year 1 actions likely focus on data collection you propose to implement to improve the • Program to be data based and outcome quality of care provided to members. focused (Limit to two pages.) • Anticipated programs should focus on target population requirements e.g. early prenatal care, chronic care management 56. Describe how you will encourage • Financial support or financial incentives providers to use electronic medical desired records. (Limit to two pages.) 57. What methods will you use to ensure the If emergent care, quality of care delivered by out-of-network • Care subject to concurrent review once case providers? is known (Limit to two pages.) • 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 Method to assess problem: disparities in treatment among disparate • Ideally, analysis of claims data races and ethnic groups and correct those • At a minimum, use of specific public health disparities. and local demographic data (Limit to four pages.) Anticipated intervention: • Targeted member education materials 28
  • 29. MississippiCAN Program RFP# 20090127 Office of the Governor – Division of Medicaid Award 1 - 5 Pts (1 being least # Statement/Question Response Elements effective, 5 being most effective) • 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 complies with DOM requirements process specifically addressing: and includes • Compliance with State o Before the hearing, the beneficiary requirements as described on and/or his or her legal representative DOM’s website have the right to review the case file • Levels of review and timing and all records that will be used at the • Process for expedited review hearing in support of the adverse • How complaints and grievances decision. are tracked and trended and how o The Hearing Officer must be impartial you use the data to make and cannot engage in ex parte changes to procedures and communications with either side. processes o The hearing decision is based solely (Limit to four pages.) 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 required if the sole issue is a Federal or State law requiring an automatic 29
  • 30. MississippiCAN Program RFP# 20090127 Office of the Governor – Division of Medicaid Award 1 - 5 Pts (1 being least # Statement/Question Response Elements effective, 5 being most effective) 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 • Do you want to require participation in satisfaction with your performance and CAHPS? services. Include how this data is used in • Annual survey of membership including ongoing quality improvement efforts. description of how survey will be (Limit to two pages.) 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 settings Subcontractors 61. If you propose to use subcontractors to • Subcontractors should not be used for “core” provide any of the services called for in CCO services such as utilization this RFP, provide a listing of those management, case management, quality subcontractors with their experience in management, provider recruitment. providing care to Medicaid members and • Prior Medicaid experience highly preferred. a brief description of the services they will provide if not already described. 62. Describe your subcontractor oversight Contracts with subcontractors should include program. Specifically describe how you compliance with all requirements in the contract will: between DOM and the CCO. • Ensure receipt of all required data • Program described for on-going monitoring of 30
  • 31. MississippiCAN Program RFP# 20090127 Office of the Governor – Division of Medicaid Award 1 - 5 Pts (1 being least # Statement/Question Response Elements effective, 5 being most effective) including encounter data subcontractors • Ensure that utilization of health • Responsibility for oversight clearly assigned. 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 31
  • 32. MississippiCAN Program RFP# 20090127 Office of the Governor – Division of Medicaid MississippiCAN Program RFP #20090127 Evaluation Tool Sections 5.7 – 5.8 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 Project Management and Control: 50 5.7 1. Does the proposal contain Sign-off procedures for completion of 5 Project all deliverables and major activities? Management and Control 2. Does the proposal contain a method to manage performance Is there a Gant chart or work 5 standards, milestones and/or deliverables? plan with dates and responsible parties to manage the project? Do the dates seem reasonable and meet the DOM deadlines? 3. Does the proposal have a way to assess project risks and an Is there a contingency plan 10 approach to managing them? 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? 4. Does the proposal have a plan for anticipating problem areas and Preferred response will 10 the approach to management of these areas, including loss of include the potential to pull required personnel? staff from other parts of their organization to temporarily fill key positions. 5. Does the proposal have a project status reporting, including 5 examples of types of reports? 6. Does the proposal have an approach to problem identification and 10 resolution? 32
  • 33. MississippiCAN Program RFP# 20090127 Office of the Governor – Division of Medicaid 7. Does the proposal have an approach to DOM’s interaction with 5 contract management staff? Maximum Possible Points for Work Plan and Schedule: 50 5.8 1. Does the proposal include a work plan, showing the start and end 20 Work plan and dates for all tasks and subtasks, indicating the interrelationships of Schedule all tasks and subtasks, and identifying the critical path as well as all responsibilities, milestones, and deliverables outlined in this RFP? 2. Does the proposal include a Gantt chart, showing the planned 15 start and end dates of all tasks and subtasks? 3. Does the proposal provide that all deliverables have a minimum of 15 five (5) workdays for review by DOM? 33

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