Colorado Department of Health Care Policy and Financing Solicitation #: HCPFRFPLL14MEDICAIDDENTAL Medicaid Dental Coverage
Table of Contents INTRODUCTION...3 1.1. GENERAL INFORMATION...3 TERMINOLOGY...3 2.1. ACRONYMS, ABBREVIATIONS AND OTHER TERMINOLOGY...3 BACKGROUND INFORMATION...6 3.1. THE DEPARTMENT OF HEALTH CARE POLICY AND FINANCING...6 3.2. PROJECT BACKGROUND...6 OFFEROR S MANDATORY QUALIFICATIONS AND EXPERIENCE 7 4.1. MANDATORY STAFFING QUALIFICATIONS...7 4.2. SPECIFIC EXPERIENCE...9 STATEMENT OF WORK...11 5.1. CONTRACTOR S GENERAL REQUIREMENTS...11 5.2. PROVISION OF SERVICES...22 5.3. ENROLLEE CHOICE OF PROVIDER...25 5.4. PROVIDER SERVICES AND SUPPORT...28 5.5. ELIGIBILITY AND ENROLLMENT...33 5.6. ENROLLEE SERVICES...35 5.7. CONTACT CENTER...39 5.8. DENTAL PROGRAM WEBSITE...40 5.9. COORDINATION WITH OTHER DEPARTMENT CONTRACTORS...42 5.10. ENCOUNTER CLAIMS / MMIS SYSTEM INTEGRATION...42 5.11. UTILIZATION MANAGEMENT...43 5.12. UTILIZATION REVIEW...49 5.13. CONTRACTOR INTERNAL COMPLIANCE...55 5.14. PERFORMANCE STANDARDS...55 5.15. CORRECTIVE ACTION PLAN...56 5.16. QUALITY IMPROVEMENT...57 5.17. REPORTING REQUIREMENTS...57 5.18. START-UP AND CLOSEOUT PERIODS...60 COMPENSATION...64 HCPFLL14MEDICAIDDENTAL Page 1 of 70
6.1. COMPENSATION...64 6.2. PAYMENT METHODOLOGY FOR REIMBURSEMENT FOR SERVICES...66 6.3. PAYMENT OF MONTHLY ADMINISTRATIVE SERVICES FEE...66 EVALUATION METHODOLOGY...67 7.1. EVALUATION PROCESS...67 7.2. EVALUATION COMMITTEE...68 7.3. COMPLIANCE...69 7.4. TECHNCIAL PROPOSAL EVALUATION CRITERIA...69 APPENDIX A - ADMINISTRATIVE INFORMATION DOCUMENT APPENDIX B - RFP SIGNATURE PAGE APPENDIX C - W-9 FORM APPENDIX D - DRAFT CONTRACT APPENDIX E - MEMBER RIGHTS APPENDIF F - DISCLOSURES APPENDIX G - PRICING WORKSHEET APPENDIX E - CASELOAD AND EXPENDITURES ESTIMATES HCPFLL14MEDICAIDDENTAL Page 2 of 70
INTRODUCTION 1.1. GENERAL INFORMATION 1.1.1. The Colorado Department of Health Care Policy and Financing (Department) is soliciting competitive, responsive proposals from experienced and financially sound organizations to perform as an Administrative Service Organization for the State s Medicaid Dental Program for the Department. 1.1.2. General solicitation information, timelines and proposal submission requirements are available in Appendix A, Administrative Information Document. To be considered responsive, an Offeror shall comply with all of the requirements and timelines contained in Appendix A. TERMINOLOGY 2.1. ACRONYMS, ABBREVIATIONS AND OTHER TERMINOLOGY 2.1.1. Acronyms, abbreviations and other terminology are defined at their first occurrence in this Request for Proposals (RFP). The following list is provided to assist the reader in understanding acronyms, abbreviations and terminology used throughout this document. 2.1.1.1. Business Day - Any day in which the Department is open and conducting business, but shall not include weekend days or any day on which one of the Department s holidays are observed. The Department observes all holidays listed in the Colorado Revised Statutes (C.R.S.) 24-11-101(1), as follows: New Year s Day. Martin Luther King Jr. Day. Washington-Lincoln Day. Memorial Day. Independence Day. Labor Day. Columbus Day. Veterans Day. Thanksgiving Day. Christmas Day. 2.1.1.2. Business Interruption - Any event that disrupts the Contractor s ability to complete the Work for a period of time, and may include, but is not limited to a Disaster, power outage, strike, loss of necessary personnel or computer virus. 2.1.1.3. CBMS The Colorado Benefits Management System A multi-agency system containing eligibility rules through which applications for Medical Assistance are processed to determine eligibility for Colorado Medicaid and Child Health Plan Plus programs; as well as eligibility for other non-medical public programs. HCPFLL14MEDICAIDDENTAL Page 3 of 70
2.1.1.4. CFR - The Code of Federal Regulations. 2.1.1.5. CHP+ - The Colorado Child Health Plan Plus. 2.1.1.6. Claims Accuracy - Measured as the number of claims processed correctly divided by the number of claims in the audit sample. 2.1.1.7. Claims Turnaround Time - Measured from the date all information is available to process the claim to the date the check is mailed or when the electronic fund transfer is initiated. 2.1.1.8. Closeout Period - The period from the earlier of ninety (90) days prior to the end of the last renewal year of the Contract or notice by the Department of non-renewal until the day that the Department has accepted the final deliverable for the Closeout Period and has determined that the final transition is complete. 2.1.1.9. Contract - The agreement that is entered into as a result of this solicitation. 2.1.1.10. Contractor - The individual or entity selected as a result of this solicitation to complete the Work contained in the Contract. 2.1.1.11. Department - The Colorado Department of Health Care Policy and Financing, a department of the government of the State of Colorado. 2.1.1.12. Disaster - An event that makes it impossible for the Contractor to perform the Work out of its regular facility, and may include, but is not limited to, natural disasters, fire or terrorist attacks. 2.1.1.13. Dollar Accuracy - Measurement based on an audit sample as total claim dollars paid correctly divided by the total claim dollars paid in the audit sample. 2.1.1.14. Effective Date - The effective date defined in the Contract. 2.1.1.15. Emergency Treatment Treatment as defined in Section 8.201.2.C of the Colorado Medicaid State Plan. 2.1.1.16. Enrollee A Medicaid recipient who is enrolled in the Colorado Medicaid Dental Program. 2.1.1.17. EPSDT Early and Periodic Screening, Diagnosis and Treatment. A federally mandated benefit that provides comprehensive and preventative health care services for children and youth ages twenty (20) and under. EPSDT is key to assuring that children and youth receive appropriate services, including assessment, following the Colorado periodicity schedule, providing screening tests to detect potential problems, performing diagnostic testing and treatment to control, correct or ameliorate any problems found. 2.1.1.18. Essential Community Providers ( ECP ) - A health care Provider that has historically served medically needy or medically indigent patients and demonstrates a commitment to serve low-income and medically indigent populations who make up a significant portion of its patient population, or in the case of a sole community Provider, serves medically indigent patients within its medical capability; and waives charges or charges for services on a sliding scale based on income and does not restrict access or services because of a person s financial limitations. HCPFLL14MEDICAIDDENTAL Page 4 of 70
2.1.1.19. Fiscal Agent- The Contractor that operates and maintains the Departments Medicaid Management Information System (MMIS). 2.1.1.20. Health/Dental Plan Enrollment Once an individual has been determined eligible for Medicaid benefits, he or she may be enrolled with a Health Plan or for a Dental Plan to receive services. This enrollment includes, but is not limited to, managed care, MCO and ASO arrangements. 2.1.1.21. HIPAA - The Health Insurance Portability and Accountability Act of 1996. 2.1.1.22. Insure Kids Now - Provides information about Medicaid and CHIP services for families who need health insurance coverage. 2.1.1.23. Key Personnel - The position or positions that are specifically designated as such in the Contract. 2.1.1.24. Medical Appropriateness or Medically Appropriate - Health care that is provided in a timely manner and meets professionally recognized standards of acceptable medical care; is delivered in the appropriate medical setting; and is the least costly of multiple, equally-effective alternative treatments or diagnostic modalities as cited in Colorado Medicaid Program regulations. 2.1.1.25. Medicaid Eligible Any individual determined eligible for Medicaid benefits based on eligibility criteria defined by Federal Regulation and State Statute, as administered by the Department of Health Care Policy and Financing through the Colorado Benefits Management System (CBMS). 2.1.1.26. Medicaid Management Information System (MMIS) - The Department s automated claims processing and information retrieval system certified by CMS. 2.1.1.27. Medically Necessary/Medical Necessity - A Medical Assistance program, good, or service that will, or is reasonably expected to prevent, diagnose, cure, correct, reduce, or ameliorate the pain and suffering, or the physical, mental, cognitive, or developmental effects of an illness, injury, or disability. It may also include a course of treatment that includes mere observation or no treatment at all. The good or service must meet all of the following: Provided in accordance with generally accepted standards of medical practice in the United States. Clinically appropriate in terms of type, frequency, extent, site, and duration. Not primarily for the economic benefit of the provider or for the convenience of the Enrollee, caretaker, or Provider. Performed in a cost effective and most appropriate setting required by the Enrollee s condition. 2.1.1.28. Medicaid Provider Identification Number A unique number assigned by the Medicaid Fiscal Agent which identifies the contract through which billing, payment, and data tracking occur. 2.1.1.29. Offeror - Any individual or entity that submits a proposal, or intends to submit a proposal, in response to this solicitation. HCPFLL14MEDICAIDDENTAL Page 5 of 70
2.1.1.30. Other Personnel - Individuals and Subcontractors, in addition to Key Personnel, assigned to positions to complete tasks associated with the Work outlined in this solicitation. 2.1.1.31. PHI - Protected Health Information. 2.1.1.32. Provider - Any health care professional or entity that has been accepted as a provider in the Colorado Medicaid as determined by the Department. 2.1.1.33. Start-Up Period - The period from the execution of the Contract, until the Operational Start Date. 2.1.1.34. State Fiscal Year (SFY) - The twelve (12) month period beginning on July 1st of a year and ending on June 30th of the following year. 2.1.1.35. Subcontractor - Third-parties, if any, engaged by Contractor to aid in performance of its obligations under the Contract. 2.1.1.36. Work - The tasks and activities Contractor is required to perform to fulfill its obligations under the Contract, including the performance of any services and delivery of any goods. BACKGROUND INFORMATION 3.1. THE DEPARTMENT OF HEALTH CARE POLICY AND FINANCING 3.1.1. The Department serves as the Medicaid Single State Agency, as defined by Code of Federal Regulations (CFR) Title 45 Section 205.100 (45 CFR 205.100). The Department develops and implements policy and financing for Medicaid and the Children's Health Insurance Program, called Child Health Plan Plus (CHP+) in Colorado, as well as a variety of other publicly funded health care programs for Colorado's low-income families, children, pregnant women, the elderly and people with disabilities. For more information about the Department, visit www.colorado.gov/hcpf. 3.1.2. The Department is a Covered Entity under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) (United States Code [U.S.C.] Title 42 Sections 1320d through 1320d-8 [42 U.S.C. 1320d 1320d-8]) and its implementing regulations. 3.2. PROJECT BACKGROUND 3.2.1. In 2011, Colorado was one of only ten states that did not offer non-emergent adult oral health services through Medicaid. Research has shown that untreated oral health conditions negatively affect a person s overall health, that gum disease has been linked to diabetes, heart disease, strokes, kidney disease, Alzheimer s disease, and even mental illness and that regular dental care and prevention are the most cost effective method to prevent minor oral conditions from developing into more complex oral and physical conditions that would eventually require emergency and palliative care. Due to these facts, Colorado SB13-242 created an adult dental benefit adult dental fund titled C.R.S. 25.5-5-207. SB13-242 was signed into law by the Governor on May 11, 2013. 3.2.2. The Department projects that approximately nine hundred forty thousand (940,000) individuals will be eligible for Medicaid in SFY 2014-15. This projection includes four hundred eighty thousand (480,000) adults and four hundred sixty thousand (460,000) children. The projected Medicaid eligible adult population has not received dental benefits HCPFLL14MEDICAIDDENTAL Page 6 of 70
in the past, and therefore it is difficult to approximate their utilization of dental benefits. Medicaid eligible children have a comprehensive dental benefit with utilization at approximately fifty percent (50%). 3.2.3. The Colorado Medicaid Dental Program ( the Program ) discussed in this RFP will include adults and children covered under Medicaid as provided for under C.R.S. 25.5-5-207 and SB13-230. The Department anticipates the inclusion of Enrollees from the Colorado Child Health Plan Plus (CHP+) and other plans at some point in the future. 3.2.4. Colorado Fiscal Note SB13-242 allows each adult up to one thousand dollars ($1,000.00) per year in routine dental benefits such as exams, cleanings and necessary work in a calendar year. Children have no such limit. 3.2.5. The selected contractor will serve as the Department s Administrative Service Organization (ASO) for the Department s network of Providers. 3.2.6. Under Colorado Medicaid, applications for entities to become a Colorado Medicaid Provider are processed by the Department s Fiscal Agent. To become a Medicaid Provider, medical and dental entities complete the Medicaid Provider Agreement Application and send completed applications to the Department s Fiscal Agent. The Fiscal Agent checks for completeness and enrolls approved Providers. The Fiscal Agent sends the approved Provider the Approval Letter and Notification of its Medicaid ID usually within eight (8) business days of receipt of completed application. OFFEROR S MANDATORY QUALIFICATIONS AND EXPERIENCE 4.1. MANDATORY STAFFING QUALIFICATIONS 4.1.1. Mandatory Key Personnel Experience and/or Qualification Requirements 4.1.2. Offeror shall designate people to hold the Key Personnel positions as specified in this solicitation. The Contractor shall not allow for any individual to fill more than one of the roles defined as Key Personnel. 4.1.2.1. Offeror s Key Personnel shall meet all mandatory experience and/or qualification requirements for Offeror to be considered for award of the Contract. These positions must all be geographically located in the State of Colorado in the greater Denver metropolitan area unless otherwise approved by the Department. 4.1.2.2. Any Offeror that does not designate Key Personnel or is unable to demonstrate that their Key Personnel meet all stated requirements will be disqualified. 4.1.2.3. The Key Personnel identified for this Contract are: Contract Manager. Provider Relations Lead. Dental Director. 4.1.2.4. Offeror s Contract Manager shall: Be a full time employee of the Contractor. HCPFLL14MEDICAIDDENTAL Page 7 of 70
Possess a Bachelor s degree. Possess at least five (5) years professional experience with knowledge in contract compliance/management and a demonstrated ability to work with multiple organizations. 4.1.2.5. Offeror s Provider Relations Lead shall: Be a full time employee of the Contractor. Possess at least two (2) years of experience in: 4.1.2.5.2.1. Coordinating Enrollee and Provider disputes, including appeals, for any relevant governmental program with an Enrollee population of at least one hundred thousand (100,000) Enrollees. 4.1.2.5.2.2. Customer Service. 4.1.2.5.2.3. Provider Relations. Possess a Bachelor s degree. Have at least three (3) years management and supervisory experience in the healthcare field. 4.1.2.6. Offeror s Dental Director shall: Be a full time employee of the Contractor. Be licensed by the Colorado Board of Dentistry and in good standing. Possess a Doctor of Dental Sciences or Doctor of Dental Medicine degree. Possess at least two (2) years of experience coordinating Enrollee and Provider disputes, including appeals, for any relevant governmental program with an Enrollee population of at least one hundred thousand (100,000) Enrollees. 4.1.3. Mandatory Other Personnel Requirements 4.1.3.1. Offeror shall provide Other Personnel, individuals in addition to Key Personnel, to ensure Offeror s ability to complete the Work. Other Personnel may consist of Offeror s employees and/or a Subcontractor(s) of the Offeror. The Offeror shall clearly explain all plans to utilize a Subcontractor(s) in its proposal. 4.1.3.2. Offeror shall use its discretion to determine all Other Personnel it will require to complete the Work. 4.1.3.3. Offeror shall ensure that the Other Personnel have previous experience, education and/or training that demonstrate that they are qualified for the positions on this project to which they will be assigned. 4.1.3.4. Any Offeror unable to demonstrate that it has sufficient Other Personnel to complete the Work will be disqualified. OFFEROR'S RESPONSE 1. Provide the name of the person to be assigned to each Key Personnel position. In addition to the name, include a work history that documents HCPFLL14MEDICAIDDENTAL Page 8 of 70
how the individual meets the mandatory minimum required skills, knowledge and experience and/or qualification requirements stated for the Key Personnel position for which the person is to be assigned. The work history summary shall not exceed three (3) pages per Key Personnel. Work history shall be added as Attachment A to the Offeror s Proposal. OFFEROR'S RESPONSE 2. Provide a summary that explains Offeror s plans for providing sufficient experienced Other Personnel to ensure Offeror s ability to complete the Work outlined in this solicitation. In addition to the summary, for all positions to be held by Other Personnel, provide the following: a. Position Title and Number of People to hold that Position Title. b. Estimated Number of Hours Per Week Each Person in the Position Will Be Dedicated to this Project. c. Offeror s ability to meet deadlines and provide deliverables in accordance with the Statement of Work. d. General work/duties/responsibilities to be assigned to Position. NOTE: If any positions are to be held by an employee of a Subcontractor or if any work/duties/responsibilities are to be completed by a Subcontractor, information about the Subcontractor s organization must be provided. For each Subcontractor, provide the following: 4.2. SPECIFIC EXPERIENCE i. Legal and Trade name of Subcontractor. ii. General work/duties/responsibilities to be assigned to Subcontractor. iii. Subcontractor s summary of the scope of work for previous project(s) including at minimum, the number of Enrollees served. iv. Brief description of each Subcontractor s skills and experience that make that Subcontractor qualified to perform the Work. 4.2.1. In addition to meeting the Mandatory Staffing Qualifications, the Department has determined that it desires specific experience and/or skills for an Offeror to possess in order for the Offeror to be able to complete the Work efficiently while meeting the demands and deadlines of the Department. 4.2.2. The Department will evaluate the Offeror's experience within the past ten (10) years with the following: HCPFLL14MEDICAIDDENTAL Page 9 of 70
4.2.2.1. The Offeror s previous experience with governmental contracts including: Operation and administration of programs with an Enrollee population similar to that of Colorado Medicaid. The number of other states in which the Offeror has operated. The size and scope of the Offeror s previous contracts. The duration of the Offeror s previous contracts. The Enrollee population size of the Offeror s previous contracts. The variety of models utilized by the Offeror in the Offeror s previous contracts. Enrollee satisfaction results from recipients of the Offeror s previous contracts. Provider satisfaction results from recipients of the Offeror s previous contracts. Operating an Enrollee and Provider Contact Center, as described in Section 5.7. Utilization Management, as described in Section 5.11. Utilization Review, as described in Section 5.12. 4.2.2.2. The Offeror s access to a network of professionals with specialized knowledge regarding the following populations: Elderly Pediatric Disability Community OFFEROR'S RESPONSE 3. Provide details of at least one (1) and no more than five (5) projects that clearly document that the Offeror s organization has experience under Section 4.2.2.1. within the last ten (10) years with the successful operation and administration providing comprehensive oral health services to an Enrollee population similar to that of Colorado Medicaid. For each project include the following: a. All relevant experience under 4.2.2.1. b. A summary of the Statement of Work for the project. c. The number of Enrollees served and the size of the Provider Network. d. The annual budget of the project. e. The legal name of the entity (or entities) with whom the Offeror had (has) a contract. HCPFLL14MEDICAIDDENTAL Page 10 of 70
f. The start and end dates of the project, or if the project is current list as ongoing. If the project has terminated or ended provide the reason for the termination or ending of the project. g. The names and contact information of two (2) individuals outside of the Offeror s organization with knowledge of the project who can speak to the relevant aspects of the work. Contact information shall include, at a minimum, the individual s affiliation and title, address, telephone number, and email address. OFFEROR'S RESPONSE 4. Provide a detailed description of the Offeror s access to a peer network of professionals as described in Section 4.2.2.2. including examples of access to networks of professionals with specialized knowledge, specifically knowledge of elderly, pediatric, and disability community dental care. STATEMENT OF WORK 5.1. CONTRACTOR S GENERAL REQUIREMENTS 5.1.1. The Department will contract with only one (1) organization, the Contractor, and will work solely with that organization with respect to all tasks and deliverables to be completed, services to be rendered and performance standards to be met. 5.1.2. The Contractor may be privy to internal policy discussions; contractual issues; price negotiations; confidential medical information; Department financial information; and advance knowledge of legislation. The Contractor shall consider and treat any such information as confidential and shall not disclose it to any third party without the written consent of the Department. 5.1.3. The Contractor shall work cooperatively with key Department staff and, if applicable, the staff of other contractors in the course of the Contract period to ensure the success of the Work. The Department may, in its sole discretion, use other contractors to perform activities related to the Work that are not contained in the Contract. 5.1.4. The Contractor shall inform Department management staff on current trends and issues in the dental/oral healthcare marketplace and provide information on new technologies in use that may impact the Contractor s responsibilities under this Contract. 5.1.5. The Contractor shall maintain complete and detailed records of all meetings, system development life cycle documents, presentations, project artifacts and any other interactions or deliverables related to the project described in the Contract. The Contractor shall make such records available to the Department upon request, throughout the term of the Contract. 5.1.6. Project Personnel 5.1.6.1. Personnel General Requirements The Contractor shall provide qualified Key Personnel and Other Personnel to perform the Work. The Contractor shall provide the Department with a final list of individuals assigned to the Contract. 5.1.6.1.1.1. DELIVERABLE: Final list of names of the individuals assigned to the Contract. HCPFLL14MEDICAIDDENTAL Page 11 of 70
5.1.6.1.1.2. DUE: Within five (5) business days after the Effective Date. The Contractor shall obtain written approval from the Department for individuals proposed for assignment to Key Personnel positions prior to those individuals beginning the performance of any Work under the Contract. The Contractor shall not voluntarily change individuals in Key Personnel positions without the prior written approval of the Department. The Contractor shall supply the Department with the name(s), resume and references for any proposed replacement whenever there is a change to Key Personnel. Any individual replacing Key Personnel shall have qualifications that are equivalent to or exceed the qualifications of the individual that previously held the position, unless otherwise approved, in writing, by the Department. 5.1.6.1.3.1. DELIVERABLE: Name(s), resume(s) and references for the person(s) replacing anyone in a Key Personnel position. 5.1.6.1.3.2. DUE: At least five (5) business days prior to the change in Key Personnel. In the event that any individual filling a Key Personnel position leaves employment with the Contractor, the Contractor shall propose a replacement person to the Department. The replacement person shall have qualifications that are equivalent to or exceed the qualifications of the individual that previously held the position, unless otherwise approved, in writing, by the Department. 5.1.6.1.4.1. DELIVERABLE: Name(s), resume(s) and references for the person(s) replacing anyone in a Key Personnel position who leaves employment with the Contractor. 5.1.6.1.4.2. DUE: Within ten (10) Business Days following the Contractor s receipt of notice that the person is leaving employment. The Contractor s Key Personnel shall perform the majority of their work and responsibilities on this project in the Denver metropolitan area, unless the Department grants permission otherwise in writing. The Contractor shall maintain appropriate staffing levels throughout the term of the Contract. If any of the Contractor's Key Personnel, or Other Personnel, are required to have and maintain any professional licensure issued by any federal, state or local government agency, then the Contractor shall submit copies of such current licenses to the Department. 5.1.6.1.7.1. DELIVERABLE: All current professional licensure documentation as specified for Key Personnel or Other Personnel. 5.1.6.1.7.2. DUE: Within five (5) business days of receipt of updated licensure or upon request by the Department. 5.1.6.2. Personnel Availability The Contractor shall ensure Key Personnel and other personnel assigned to the Contract are available for meetings with the Department during the Department s normal business hours. The Contractor shall also make these personnel available HCPFLL14MEDICAIDDENTAL Page 12 of 70
outside of the Department s normal business hours and on weekends with prior notice from the Department. The Contractor s Key Personnel and other operational staff shall be available for all regularly scheduled meetings between the Contractor and the Department, unless the Department has granted prior, written approval otherwise. The Contractor shall ensure that the staff attending all meetings between the Department and the Contractor have the authority to represent and commit the Contractor regarding work planning, problem resolution and program development. At the Department s direction, the Contractor shall make its Key Personnel and other personnel assigned to the Contract available to attend meetings as subject matter experts with stakeholders both within the State government and with external or private stakeholders. All of the Contractor s personnel that attend any meeting with the Department or other Department stakeholders shall be physically present at the location of the meeting, unless the Department gives prior, written permission to attend by telephone or video conference. In the event that the Contractor has any personnel attend by telephone or video conference, the Contractor shall be responsible for providing the conference line or virtual meeting place. The Contractor shall respond to all telephone calls, voicemails and emails from the Department within one (1) Business Day of receipt by the Contractor. 5.1.6.3. Key Personnel Responsibilities Contract Manager 5.1.6.3.1.1. The Contract Manager shall: 5.1.6.3.1.1.1. Monitor all phases of the project in accordance with work plans or timelines or as determined between the Contractor and the Department. 5.1.6.3.1.1.2. Serve as Contractor s primary point of contact for the Department. 5.1.6.3.1.1.3. Be responsible for completion and/or submission of all tasks and deliverables in the Contract. Provider Relations Lead 5.1.6.3.2.1. The Provider Relations Lead shall: 5.1.6.3.2.1.1. Educate in-network and out-of-network providers regarding appropriate claims submission requirements, coding updates, electronic claims transactions and electronic fund transfer, and available resources. 5.1.6.3.2.1.2. Be responsible for network development and management to ensure that there is a statewide dental network adequate to make services, service locations and service sites available and accessible in accordance with the terms and conditions for access and availability outlined in the contract. 5.1.6.3.2.1.3. Coordinate with other areas of the Contractor s organization that may impact provider recruitment, retention or termination. HCPFLL14MEDICAIDDENTAL Page 13 of 70
5.1.6.3.2.1.4. Ensure that the provider enrollment file and the Insure Kids Now (IKN) files are accurate and delivered to Colorado Medicaid timely. 5.1.6.3.2.1.5. Maintain the toll free number for Providers and compile, analyze, and disseminate information from provider calls. 5.1.6.3.2.1.6. Identify trends and guide the development and implementation of strategies to improve provider satisfaction. 5.1.6.3.2.1.7. Oversee dedicated provider relations staff for providers to contact via telephone, electronic mail, surface mail, website, and in person, to ask questions, file a provider complaint and resolve problems. 5.1.6.3.2.1.8. Be the primary contact for dental offices and provide education and training regarding enrollment. 5.1.6.3.2.1.9. Resolve service issues. Dental Director 5.1.6.3.3.1. The Dental Director shall: 5.1.6.3.3.1.1. Oversee and be responsible for the proper provision of medically necessary covered services for Enrollees. 5.1.6.3.3.1.2. Monitor all of the following: 5.1.6.3.3.1.2.1. Utilizations management and review. 5.1.6.3.3.1.2.2. Provider corrective action. 5.1.6.3.3.1.2.3. Site visits. 5.1.6.3.3.1.2.4. Referral management. 5.1.6.3.3.1.2.5. Appeals. 5.1.6.3.3.1.2.6. Grievances. 5.1.6.3.3.1.2.7. Performance Improvement Projects (PIPs). 5.1.6.3.3.1.3. Attend all Colorado Dental Advisory Committee meetings and be on the quarterly meeting agenda to present recommendations regarding changes to clinical guidelines when requested by the Department. 5.1.6.3.3.1.4. Manage the clinical aspects of the project, including, but not limited to afterhours consultation, as needed. 5.1.6.4. The Contractor shall provide an Education and Outreach Coordinator. The Education and Outreach Coordinator shall: 5.1.6.4.1.1. Support coordinated enrollment efforts with partners. 5.1.6.4.1.2. Ensure culturally and linguistically appropriate outreach and enrollment efforts. 5.1.6.4.1.3. Target underserved populations and areas for innovative patient outreach and provider enrollment efforts. 5.1.6.4.1.4. Coordinate with Healthy Communities outreach and case management program HCPFLL14MEDICAIDDENTAL Page 14 of 70
manager as well as local contracted programs to assure services are not duplicative in nature. 5.1.6.5. Other Personnel Responsibilities Provider Relations Representatives 5.1.6.5.1.1. The Contractor shall designate and maintain, subject to Department approval, a minimum of three (3) full-time Provider Relations Representatives physically located in Colorado to: 5.1.6.5.1.1.1. Educate and assist participating dental providers with utilization management programs including, but not limited to, prior authorization requests, electronic billing, compliance initiatives, and other program requirements. 5.1.6.5.1.1.2. Provide ongoing Provider training, respond to Provider inquiries and provide general assistance to Providers regarding program operations and requirements. 5.1.6.5.1.1.3. Communicate with providers to ensure the effective exchange of information and to gain feedback. 5.1.6.5.1.1.4. Ensure regularly scheduled visits to Provider sites, as well as ad hoc visits as circumstances dictate. Outreach and Education Representatives 5.1.6.5.2.1. The Contractor shall designate and maintain, subject to Department approval, a minimum of two (2) full-time Outreach and Education Representatives physically located in Colorado to: 5.1.6.5.2.1.1. Promote state-wide oral health awareness with schools, community and public health advocates and others. 5.1.6.5.2.1.2. Provide assistance to enroll dental practices. 5.1.6.5.2.1.3. Provide assistance partnering Enrollees with Providers. 5.1.6.5.2.2. At least one (1) Outreach and Education Representative shall maintain an active Colorado dental hygiene license. The Contractor shall ensure that all Other Personnel have sufficient training and experience to complete all portions of the Work assigned to them. The Contractor may subcontract to complete a portion of the Work required by the Contract. The conditions for using a Subcontractor(s) are as follows: 5.1.6.5.4.1. The Contractor shall not subcontract more than forty percent (40%) of the Work. 5.1.6.5.4.2. The Contractor shall provide the organizational name of each Subcontractor and all items to be worked on by each Subcontractor to the Department. 5.1.6.5.4.2.1. DELIVERABLE: Name of each Subcontractor and items on which each Subcontractor will work. 5.1.6.5.4.2.2. DUE: The later of thirty (30) days prior to the Subcontractor beginning work HCPFLL14MEDICAIDDENTAL Page 15 of 70
or the Effective Date. 5.1.6.5.4.3. The Contractor shall obtain prior consent and written approval for any change in the use of Subcontractor(s). Notice of Subcontractor Termination. 5.1.6.5.5.1. When a subcontract that relates to the provision of services to Enrollees or claims processing is being terminated between the Contractor and a subcontractor, the Contractor shall give at least thirty (30) days prior written notice of the termination to Colorado Medicaid. Notices shall include, at a minimum: 5.1.6.5.5.1.1. Contractor s intent to change to a new subcontractor or subcontractors for the provision of Work. 5.1.6.5.5.1.2. A termination and/or change date. 5.1.6.5.5.1.3. Other pertinent information that may be needed to access services. 5.1.6.5.5.2. Upon request, the Contractor shall provide Colorado Medicaid with a Subcontractor Transition Plan, which shall include, at a minimum: 5.1.6.5.5.2.1. Information regarding how prior authorization requests will be handled during and after the transition, if applicable. 5.1.6.5.5.2.2. How continuity of care will be maintained for the Enrollees Deliverables 5.1.7. Deliverables 5.1.7.1. All deliverables shall meet Department-approved format and content requirements. The Department will specify the number of copies and media for each deliverable. 5.1.7.2. Each deliverable will be reviewed by the Department and shall require formal, written approval from the Department before acceptance of the deliverable. The Contractor shall allow for a minimum of ten (10) Business Days following receipt, per deliverable, for the Department to review each deliverable and document its findings, except as specified herein. Based on the review findings, the Department may accept the deliverable, reject portions of the deliverable, reject the complete deliverable or require that revisions be made. The Contractor shall make all changes directed by the Department. Unless otherwise agreed to by the Department in writing, the Contractor shall be required to submit replacement portions or a complete revised version of the deliverable within five (5) Business Days following receipt of Department comments. The Department shall have an additional five (5) Business Day review period whenever replacement portions or a complete revised version of a deliverable is resubmitted. 5.1.7.3. The Contractor shall employ an internal quality control process to ensure that all deliverables, documents and calculations are complete, accurate, easy to understand and of high quality. The Contractor shall provide deliverables that, at a minimum, are responsive to the specific requirements, organized into a logical order, contain no spelling or grammatical errors, formatted uniformly and contain accurate information and correct calculations. The Contractor shall retain all draft and marked-up documents and checklists utilized in reviewing documents for reference through the duration of the project and project acceptance. HCPFLL14MEDICAIDDENTAL Page 16 of 70
5.1.7.4. The Contractor shall document, in writing, and deliver to the Department its responses to the Department s comments and requests for revisions or clarification of deliverable contents. 5.1.7.5. At the Department s request, the Contractor shall be required to conduct a walk-through of Department-selected deliverables to facilitate the Department's review and approval process. The walk-through shall consist of an overview of the deliverable, explanation of the organization of the deliverable, presentation of critical issues related to the deliverable and other information as requested by the Department. It is anticipated that the content of the walk-through may vary with the deliverable presented. 5.1.7.6. In the event that any due date for a deliverable falls on a day that is not a Business Day, then the due date shall be automatically extended to the next Business Day, unless otherwise directed by the Department. 5.1.7.7. All due dates or timelines that reference a period of days shall be measured in calendar days, months and quarters unless specifically stated as Business Days or otherwise. All times stated in the Contract shall be considered to be in Mountain Time, adjusted for Daylight Saving Time as appropriate, unless specifically stated otherwise. 5.1.7.8. No deliverable, report, data, procedure or system created by the Contractor for the Department that is necessary to fulfilling the Contractor's responsibilities under the Contract, as determined by the Department, shall be considered proprietary. 5.1.7.9. Any document, deliverable or other item delivered to the Department for review and approval shall require written approval by the Department before the Contractor may consider that document, deliverable or other item approved. 5.1.7.10. Written Materials to Enrollees Guidelines. All written materials sent to Enrollees shall: 5.1.7.10.1.1. Be written to a 3rd grade reading level. 5.1.7.10.1.2. Be made available in Spanish. 5.1.7.10.1.3. Be made available in Russian upon request. 5.1.8. Stated Deliverables and Performance Standards 5.1.8.1. Any section within this Statement of Work headed with or including the term "DELIVERABLE" or "PERFORMANCE STANDARD" is intended to highlight a deliverable or performance standard contained in this Statement of Work and provide a clear due date for deliverables. The sections with these headings are not intended to expand or limit the requirements or responsibilities related to any deliverable or performance standard. 5.1.9. Communication Requirements 5.1.9.1. Communication with the Department The Contractor shall enable all Contractor staff to exchange documents and electronic files with the Department staff in compatible formats. The Department currently uses Microsoft Office 2013 and/or Microsoft Office 365 for PC. If the HCPFLL14MEDICAIDDENTAL Page 17 of 70
Contractor uses a compatible program that is not the Department s current Microsoft version for PC, then the Contractor shall ensure that all documents or files delivered to the Department are completely transferrable and reviewable, without error, on the Department s systems. The Department will use a transmittal process to provide the Contractor with official direction within the scope of the Contract. The Contractor shall comply with all direction contained within a completed transmittal. For a transmittal to be considered complete, it must include, at a minimum, all of the following: 5.1.9.1.2.1. The date the transmittal will be effective. 5.1.9.1.2.2. Direction to the Contractor regarding performance under the Contract. 5.1.9.1.2.3. A due date or timeline by which the Contractor shall comply with the direction contained in the transmittal. 5.1.9.1.2.4. The signature of the Department employee who has been designated to sign transmittals. 5.1.9.1.2.4.1. The Department will provide the Contractor with the name of the person it has designated to sign transmittals on behalf of the Department, who will be the Department s primary designee. The Department will also provide the Contractor with a list of backups who may sign a transmittal within twentyfour hours on behalf of the Department if the primary designee is unavailable. The Department may change any of its designees from time to time by providing notice to the Contractor through a transmittal. The Department may deliver a completed transmittal to the Contractor in hard copy, as a scanned attachment to an email or through a dedicated communication system, if such a system is available. If the Contractor receives conflicting transmittals, the Contractor shall contact the Department s primary designee, or backup designees if the primary designee is unavailable, to obtain direction. If the Department does not provide direction otherwise, then the transmittal with the latest effective date shall control. In the event that the Contractor receives direction from the Department outside of the transmittal process, it shall contact the Department s primary designee, or backup designees if the primary designee is unavailable, and have the Department confirm that direction through a transmittal prior to complying with that direction. Transmittals may not be used in place of an amendment, and may not, under any circumstances be used to modify the term of the Contract or any compensation under the Contract. The Contractor shall retain all transmittals for reference and shall provide copies of any received transmittals upon request by the Department. 5.1.9.2. Communication with Enrollees, Providers and Other Entities The Contractor shall create a Communication Plan that includes, but is not limited to, all of the following: HCPFLL14MEDICAIDDENTAL Page 18 of 70
5.1.9.2.1.1. A description of how the Contractor will communicate to Enrollees any changes to the services those Enrollees will receive or how those Enrollees will receive the services. 5.1.9.2.1.2. A description of how the Contractor will meet Enrollee s translation needs, including, but not limited to, Spanish, Russian and sign language translation services. 5.1.9.2.1.3. A description of the communication methods, including things such as email lists, newsletters and other methods, the Contractor will use to communicate with Providers, Subcontractors, and Healthy Communities contractors. 5.1.9.2.1.4. The specific means of immediate communication with Enrollees and a method for accelerating the internal approval and communication process to address urgent communications or crisis situations. 5.1.9.2.1.5. A general plan for how the Contractor will address communication deficiencies or crisis situations, including how the Contractor will increase staff, contact hours or other steps the Contractor will take if existing communication methods for Enrollees or Providers are insufficient. 5.1.9.2.1.6. A listing of the following individuals within the Contractor s organization, that includes cell phone numbers and email addresses: 5.1.9.2.1.6.1. An individual who is authorized to speak on the record to the press, Governor s Office, and Colorado General Assembly regarding the Work, the Contract or any issues that arise that are related to the Work. 5.1.9.2.1.6.2. An individual who is responsible for any website or marketing related to the Work. 5.1.9.2.1.6.3. Back-up communication staff that can respond in the event that the other individuals listed are unavailable. The Contractor shall deliver the Communication Plan to the Department for review and approval. 5.1.9.2.2.1. DELIVERABLE: Communication Plan. 5.1.9.2.2.2. DUE: Within ten (10) Business Days after the Effective Date. The Contractor shall review its Communication Plan on an annual basis and determine if any changes are required to account for any changes in the Work, in the Department s processes and procedures or in the Contractor s processes and procedures. The Contractor shall submit an Annual Communication Plan Update that contains all changes from the most recently approved prior Communication Plan, Annual Communication Plan Update or Interim Communication Plan Update or shall note that there were no changes. 5.1.9.2.3.1. DELIVERABLE: Annual Communication Plan Update. 5.1.9.2.3.2. DUE: Annually, by June 30 th of each year. The Department may request a change to the Communication Plan at any time to HCPFLL14MEDICAIDDENTAL Page 19 of 70
account for any changes in the Work, in the Department s processes and procedures or in the Contractor s processes and procedures, or to address any communication related deficiencies determined by the Department. The Contractor shall modify the Communication Plan as directed by the Department and submit an Interim Communication Plan Update containing all changes directed by the Department. 5.1.9.2.4.1. DELIVERABLE: Interim Communication Plan Update. 5.1.9.2.4.2. DUE: Within ten (10) Business Days following the receipt of the request from the Department, unless the Department allows for a longer time in writing. The Contractor shall not implement any Communication Plan, Annual Communication Plan Update or Interim Communication Plan Update prior to receipt of the Department s written approval of that Communication Plan, Annual Communication Plan Update or Interim Communication Plan Update. The Contractor shall comply with all requirements, deliverables and milestones contained in the most recently implemented Communication Plan, Annual Communication Plan Update or Interim Communication Plan Update. 5.1.10. Business Continuity The Contractor shall not engage in any non-routine communication with any Enrollee, any Provider, the media or the public without the prior written consent of the Department. 5.1.10.1. The Contractor shall create a Business Continuity Plan that the Contractor will follow in order to continue operations after a Disaster or a Business Interruption. The Business Continuity Plan shall include, but is not limited to, all of the following: How the Contractor will replace staff that has been lost or is unavailable during or after a Business Interruption so that the Work is performed in accordance with the Contract. How the Contractor will back-up all information necessary to continue performing the Work, so that no information is lost because of a Business Interruption. 5.1.10.1.2.1. In the event of a Disaster, the plan shall also include how the Contractor will make all information available at its back-up facilities. How the Contractor will minimize the effects on Enrollees of any Business Interruption. How the Contractor will communicate with the Department during the Business Interruption and points of contact within the Contractor s organization the Department can contact in the event of a Business Interruption. Planned long-term back-up facilities out of which the Contractor can continue operations after a Disaster. The time period it will take to transition all activities from the Contractor s regular facilities to the back-up facilities after a Disaster. 5.1.10.2. The Contractor shall deliver the Business Continuity Plan to the Department for review and approval. HCPFLL14MEDICAIDDENTAL Page 20 of 70
DELIVERABLE: Business Continuity Plan. DUE: Within ten (10) Business days after the Effective Date. 5.1.10.3. The Contractor shall review its Business Continuity Plan at least semi-annually and update the plan as appropriate to account for any changes in the Contractor s processes, procedures or circumstances. The Contractor shall submit an Updated Business Continuity Plan that contains all changes from the most recently approved prior Business Continuity Plan or Updated Business Continuity Plan or shall note that there were no changes. DELIVERABLE: Updated Business Continuity Plan. DUE: Semi-annually, by June 30 th and December 31 st of each year. 5.1.10.4. In the event of any Business Interruption, the Contractor shall implement its most recently approved Business Continuity Plan or Updated Business Continuity Plan immediately after the Contractor becomes aware of the Business Interruption. In that event, the Contractor shall comply with all requirements, deliverables and milestones contained in the implemented plan. 5.1.11. Intellectual Property Ownership 5.1.11.1. In addition to the intellectual property ownership rights in the Contract, the following subsections describe the intellectual property ownership requirements that the Contractor shall meet during the term of the Contract in relation to federal financial participation. 5.1.11.2. To facilitate obtaining the desired amount of federal financial participation under 42 CFR 433.112, the Department shall have all ownership rights, not superseded by other licensing restrictions, in all materials, programs, procedures, etc., designed, purchased, or developed by the Contractor and funded by the Department. The Contractor shall use contract funds to develop all necessary materials, programs, products, procedures, etc., and data and software to fulfill its obligations under the Contract. Department funding used in the development of these materials, programs, procedures, etc. shall be documented by the Contractor. The Department shall have all ownership rights in data and software, or modifications thereof and associated documentation and procedures designed and developed to produce any systems, programs reports and documentation and all other work products or documents created under the Contract. The Department shall have these ownership rights, regardless of whether the work product was developed by the Contractor or any Subcontractor for work product created in the performance of this Contract. The Department reserves, on behalf of itself, the Federal Department of Health and Human Services and its contractors, a royalty-free, nonexclusive and irrevocable license to produce, publish or otherwise use such software, modifications, documentation and procedures. Such data and software includes, but is not limited to, the following: All computer software and programs, which have been designed or developed for the Department, or acquired by the Contractor on behalf of the Department, which are used in performance of the Contract. All internal system software and programs developed by the Contractor or HCPFLL14MEDICAIDDENTAL Page 21 of 70