Eon Health, LLC
A Request for Proposal (RFP)
For
Business Process Outsourcing
Of
Medicare Advantage Operations
1
Schedule of Key Events
RFP Release Date
March 10, 2016 5:00pm EST
Written Questions Due
March 15, 2016 5:00pm EST
Eon Health Response to Written Questions Due
March 17, 2016 5:00pm EST
Proposal Due Date
March 30, 2016 5:00pm EST
In person/Webinar Presentations
April 4, 2016 - April 13, 2016
Notification of Award
April 18, 2016 3:00pm EST
Implementation Begin Date
April 25, 2016 8:00am EST
2
Table of Contents
Designated Eon Health Contact(s) ................................................................................ 4
Purpose of Requests for Proposals ...............................................................................4
Contract Period ..............................................................................................................5
Requests for Supplemental Information Regarding Proposals ......................................5
Final Selection and Contract Award .............................................................................. 5
Notification of Award ......................................................................................................6
Background ....................................................................................................................6
About Eon Health........................................................................................................6
Detailed RFP Specifications ...........................................................................................7
3
Designated Eon Health Contact(s)
All RFP submissions and questions/responses should be submitted to:
Joseph Aggazio
President
3640 Enterprise Way
Miramar, FL 33025
[email protected]
Copy [email protected] on all email correspondence.
Response Procedures
Each vendor should submit two (2) hard copies and one (1) electronic copy of its
response to Eon Health at the address noted above.
All responses should be in the order and numbering convention of the original RFP.
While Eon Health plans to procure BPO processes, the issuance of this RFP does not
obligate Eon Health to purchase any products or services or to reimburse any recipient
or responder to the RFP for any expenses incurred in connection with responding to the
RFP. All vendors’ responses to the body of the RFP must be received no later than
[date and time] in order to be considered.
Eon Health reserves the right to make any modifications including postponing the date
and time announced for receipt of RFP responses. Such modification may be made
prior to the established date and time of receipt of RFP responses by notice and
addendum to the RFP to all potential vendors
All information contained in this RFP or provided during the review process is
confidential and proprietary. Eon Health requires this information to be used exclusively
for developing the response to this questionnaire, and each vendor will use all
reasonable efforts to limit dissemination or disclosure of this information.
The information and all supporting documentation submitted by any vendor or vendor’s
agent shall become the property of Eon Health, unless the vendor specifically requests
in writing the information and documentation be returned or destroy.
Purpose of Requests for Proposals
Eon Health intends to award a contract for Business Process Outsourcing (BPO) for a
Medicare Advantage (MA) plan(s), which is a new line of business, to launch in
October 2016, offering MA plan coverage on January 1, 2017. We are seeking best
practice for infrastructure, tools, resources, and processes aimed at compliantly,
accurately, and effectively delivering a Medicare line of business.
4
The issuance of this RFP, and the subsequent contract award, is intended to meet
several objectives. The successful bidder will be expected to provide staffing and
administrative services for the following business functions:







Eligibility, Enrollment, Disenrollment, Member Management
Fulfillment/Mail Room
Premium Billing
Claims, Including benefit and provider contract configuration
Coordination of Benefits
Member Reconciliation
Financial Reconciliation
For the purposes of this RFP, please describe only those processes that will be
performed directly by the Vendor company. Any components or processes that would
be subcontracted must be clearly labeled as such.
A mutual confidentiality statement from plan counsel will be required.
Contract Period
The contract resulting from this RFP shall be effective upon approval by Eon
Health. It is Eon Health’s intent to award a contract no later than, April 15, 2016
3:00pm EST, allowing for an 6-month implementation period prior to the Annual
Election Period (AEP). The initial term of the contract will be 3 – 5 years.
The contract will require the Vendor to comply with all applicable regulatory
requirements and may be amended in the future as requirements change.
Requests for Supplemental Information Regarding Proposals
During the evaluation period, Eon Health may request bidders to provide supplemental
information for the purpose of clarifying their proposal. This information must be
in writing and will be included as a formal part of the bidder’s proposal.
Vendor Site Visits
Eon Health may request a site visit at the location where the vendor will provide
operational, development, and implementation support. Vendor may request site
visits be conducted at a location other than the support location, but the site must
provide Eon Health with access to executive- and management-level personnel.
5
Final Selection and Contract Award
The evaluation of the bids will include but not be limited to:





The original submission of bidder’s RFP
Supplemental information regarding proposals
In-person or webinar presentations, as requested
Vendor site visit, as requested
Cost proposal
Notification of Award
After evaluation and selection of the vendor, all bidders will be notified in writing of the
selection or non-selection of their proposals. The name of the successful bidder will be
disclosed. Press releases pertaining to this project shall not be made without
prior written approval by Eon Health.
Background
Eon Health is a new Health Plan offering coverage in select southern states. Eon
Health is pursuing contracts for Medicare Advantage with Prescription Drug (MAPD)
plans, including a Dual Eligible Special Needs Plan (DSNP) and Chronic Care Special
Needs Plan (CCSNP) plans. Eon Health is a diverse health plan committed to
providing high quality health care services to the communities that we serve.
6
VENDOR EXECUTIVE SUMMARY
A. General Information
1. Provide contact information for this RFP including contact name, company name,
mailing address, phone, fax, and email.
2. Describe your organization, including your mission, vision, core capabilities, and
length of time in business, etc.
3. Describe your geographic location(s) and indicate where the services would be
handled.
4. Please provide an organizational chart of your entity.
5. Provide biographies of key management and staff responsible for this
engagement:
a. Executive
b. Project Manager
c. Each Functional Area
6. Describe staff who would be handling enrollees, including structure (e.g., a
“team” dedicated to MA business, staff embedded in functionally organized
departments, or some other approach) and whether staff members to support the
business are already Vendor employees.
7. Describe your organization’s training program by the functional area described in
this RFP; be sure to include new hire and annual training requirements.
8. Describe your company’s financial solvency and your ability to support
operational functions on an ongoing basis.
9. Describe any pending litigation or judgments against your company in the past
three years. Describe any debarment or sanction from a federal, state, or local
government program. Explain whether any existing or pending litigation or
judgment has the potential to negatively impact the financial stability or reputation
of your organization.
10. Describe the details of any and all specific conditions (financial, operational,
contractual, or otherwise) on which this proposal depends.
11. Please describe your ability to interface with other vendor’s systems.
12. Describe whether your organization subcontracts the Information System
responsibilities to any other vendor. If yes, describe this arrangement.
7
13. Describe your organization’s disaster recovery operations and systems back-up.
14. Provide a list of implementations for clients new to MA, including year of
implementation.
15. Eon Health will expect the proposing vendor to function as the primary
contractor, responsible for all functions. Should any aspects of the RFP be
delegated to a subcontractor or associated vendor, please identify all parties’
names and addresses and specify the services they will provide.
8
B. Vendor’s Medicare Background
1. Describe your organization’s expertise in processing enrollment/disenrollment,
billing, claims, call center, reconciliation, appeals, and grievances.
2. By type of plan (Health Maintenance Organization (HMO), Health Maintenance
Organization Point-of-Service (HMO-POS), Preferred Provider Organization
(PPO), or Private Fee-for-Service (PFFS), including D-SNPs and CC-SNPs,
indicate how many MA programs you administer or support and the length of
time you have been supporting such programs. Indicate the functions outsourced
to you and the approximate number of enrollees represented.
3. Please provide references for similar business, including the contact information
for each and the type of services performed on their behalf. Also list any major
clients who have terminated similar business with your company over the past
three years and the reason for termination.
4. If you operate as an insurance carrier selling MA products or an MA plan, please
list your products, the area(s) where sold, and your current membership. If you
are considering expanding your current Medicare offerings or service area,
please describe your expansion plans.
5. Describe your CMS compliance and reporting process.
6. List any fines, penalties, corrective actions or sanctions your organization has
received from CMS or the organizations to whom you provide services.
7. Please provide a copy of an implementation plan previously used by your
organization to implement an MA product with the functions listed in this RFP.
8. Please provide your key deliverable dates and milestones required for
implementation of an MA plan accepting enrollee applications as of October 15,
2016, for a January 1, 2017, effective date.
9. If available, provide any specific file formats required by your organization in
order to load benefit, membership, or provider-specific information.
10. Please provide a description of your organization’s standard Medicare reports
relative to the functions outlined in this RFP.
11. Describe your ability to pull data universes for internal or external audits,
including Medicare Part C and Part D reporting. Include time frame requirements.
12. Describe your system(s)’s Inventory Management reports (receipts, aging, and
metrics).
9
13. Describe your ability to provide ad hoc Medicare reports and the time frames
required.
C. HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA)
COMPLIANCE
1. Describe your solution(s)’s security and privacy safeguards and how they meet
HIPAA guidelines. For example, please include the ability to identify and deidentify protected health information (PHI) through user class specific business
rules.
2. Describe your solution(s)’s features for validating transactions and code sets and
protecting privacy of data during transmission and storage, such as using
encryption technologies.
3. Describe your security model and methods for data access, role-based user
access, protection of PHI data, organization and user authentication, and
network security.
4. How do/does your solution(s) provide the capability to implement row-based
security or virtual private databases for restricting user access to certain subsets
of data?
5. How do you ensure privacy and that access permissions are appropriate and
meet minimum necessity requirements to each user, group, or audience?
6. Discuss your approach to authentication (including single-sign-on). Do/does your
solution(s) have the ability to integrate with an external security service that
provides user authorization information on the content level?
7. Describe your procedures to ensure you are in compliance with HIPAA Privacy
and Security requirements in working with your customers, with respect to all
functional areas outlined in this RFP.
8. Describe any industry standard edits that will be applied to electronic claims and
the documentation given to providers describing the edits.
9. Describe the security audit and reporting capabilities of the solution(s). Is the
database encrypted? Is archived data encrypted? If yes, please describe the
encryption protocol.
10. Describe your communication processes with providers when claims do not pass
HIPAA compliance or industry standard edits. Please include examples of all
edit reports.
10
11. Describe how your solution(s) support(s) tracking of authorized users when they
are accessing data. For example, audits of PHI data access.
12. How do you keep your solution(s) compliant with new CMS regulations and
guidance within the CMS deadlines? Is there a charge to the client for these
modifications? Who is responsible for keeping abreast of the regulations and
providing specifications for any modifications?
13. Describe the testing (duration, time before deployment in production,
environment, and data) clients are allowed to perform before changes are
released into production.
14. Describe your archiving/back-up processes for extracted data. How many years
of data do you keep available online?
15. Describe how your solution(s) can prevent unintended and unauthorized
modification to business data and program code.
D. Data Quality & Integrity
1. Do/does your solution(s) include mechanisms for ensuring the integrity of data
within the repository? Explain.
2. Do/does your solution(s) include mechanisms to prevent data corruption,
inaccuracy, and loss? If yes, list the mechanisms and describe in detail how they
prevent data corruption and loss.
3. Describe how your solution(s) assess(es) the quality of data sources by a
capture of detailed metadata (e.g., ranges of data element values) and identifies
potential data quality issues.
4. Describe how solution(s) perform(s) data “clean up” by modifying data elements
based on user-defined business rules.
5. Do/does your solution(s) include mechanisms to prevent data corruption,
inaccuracy, and loss? If yes, list the mechanisms and describe in detail how they
prevent data corruption and loss.
11
E. Vendor Pricing and Bid
Please provide your organization’s charges for the services described in this RFP.
Indicate whether services are available “cafeteria style” versus as a bundled package.
Indicate whether services are on a per claim, per member per month (pmpm), monthly,
annual, or other basis. Describe whether customer service and provider service price is
transactional or based on some other methodology. Also indicate whether pricing would
vary depending on whether services were purchased “cafeteria style” versus as a
bundled package. If pricing is dependent upon volume and/or length of agreement for
each service, include the scale on which the pricing is based. Components for which
Sponsors request pricing include:
Service Component
(specific fees)
Initial
Cost
Annual
Costs
Ongoing1
Services
available a’ la
carte?
Comments/Additional
Explanation
(Yes/No)
Provide any specific contract requirements including any minimum terms of contract.
Please provide a sample of a contract you would propose for services described in this
RFP.
Please describe the amount of administrative fees your organization is willing to put at
risk for performance guarantees.
1
Include both ongoing licensing and support costs – itemization should be documented in a supplemental
Microsoft Excel workbook.
12
FUNCTIONAL AREAS
F. Enrollment
1. Describe the Medicare enrollment and eligibility processing system and the
functions supported by your solution (e.g., member elections, premium
calculation, billing, duplicates, SNP validation etc.).
2. Please provide a brief overview of your organization’s enrollment processing
system, with a specific focus on MA status tracking. Include specific components
already constructed in your system for data exchanges with CMS.
3. Describe what configuration and reference files your solution uses, how they are
loaded (workflow, whether automated or manual), and how the user can view
and export the data.
4. Describe how Medicare member election information can be loaded into your
solution, e.g., manual, electronic (file from employer group), or online (via web)
enrollment.
5. Describe your existing enrollment and disenrollment processes, including
eligibility verification, applicable business rules, enrollment record archival, SNP
validation, and fulfillment.
6. Describe your solution’s eligibility verification process:
a. Provide the level (type) of edits associated with data entry.
b. Does your solution provide the ability to add customized user edits?
c. What CMS verification mechanisms does your solution support out of the box
(e.g., BEQ)?
7. Include specific examples of acceptable file formats that support the exchange of
daily, weekly, and/or monthly enrollment data exchanges.
8. Explain the logic used by your solution to determine election periods (e.g., Initial
Enrollment Period (IEP), Special Election Period (SEP) and enrollment/
disenrollment dates, incompletes, and upfront denials.
9. Explain your solution’s automated error management/work queue process during
Medicare enrollment. Does your error management support workflow/work
queues?
10. Describe your organization’s quality control program relative to the enrollment
process.
11. Describe your solution’s correspondence capabilities and ability to configure
letters:
13
a. List the CMS model letters your solution supports out of the box.
b. Describe the process and audit capabilities from letter trigger to letter
response (if any).
12. Can your solution support multiple member identifiers (i.e., different member ID
per region for a single Medicare Health Insurance Claim Number (HICN))?
13. Describe how your solution identifies an individual and stores information about
the person prior to enrollment, after enrollment into Medicare, and following
disenrollment
14. How does your solution address “members” enrolled in more than one benefit
plan (e.g., enrolled in Medicare and a commercial plan).
15. Describe your ability to manage applications for an MA product submitted to you
from multiple sources.
16. Provide current statistics regarding the turnaround time for enrollment application
processing and mailing of related enrollee correspondence. Describe the controls
in place to ensure CMS time frames are met.
17. Please indicate your ability to produce ID cards per customer specifications, or
list any system limitations or requirements for card design.
18. If the MA product is sold by agents/brokers, please describe your ability to
coordinate member and agent communications, store and maintain agent data.
19. Describe the workflow for submitting enrollment to CMS from your solution.
Include any multi-level review process (for quality assurance) or user access
restrictions.
20. Does your solution support generation of the daily, weekly, and monthly standard
submission file from the Plan to CMS? If not, which do you support?
21. Prior to CMS submission, can your solution apply standard CMS edits and
validate against CMS data for each submission record and identify associated
errors?
a. How are such edits maintained as CMS add/removes/adjusts such edits?
b. Does you solution support the ability to add additional user defined edits?
22. Does your solution provide the ability to change records prior to CMS submission
a. Indicate how your solution maintains audit history for such changes.
b. Can the ability to make such changes be limited? If so, how?
23. Describe your solution’s submission failure reconciliation and resubmission
process?
14
24. How does your solution handle rejected transactions, automatically or manually?
25. Describe your solution’s ability to handle retroactivity (e.g., retro enroll, etc.).
26. Describe your solution’s ability to handle submissions to CMS Retro Processor
including tracking, monitoring, and follow-up.
27. Describe how your solution workflow ensures CMS requirements are met within
CMS-defined implementation timeline(s).
28. Does your solution support the CMS Daily Transaction Reply Report (DTRR) file
to the Plan?
29. Describe your solution’s ability to validate the Transaction Reply Code (TRC) and
generate different triggering events for processing.
30. Does your solution (at the TRC level) allow the ability to process or bypass action
for a given TRC?
31. Describe the data integrity checks/processes your solution has available to
maintain consistency with TRR data.
32. Explain how your solution triggers or suppresses an event as the result of a
combination of reply codes for a Medicare member in the same file.
33. Does your solution track all member status changes based upon reply codes?
34. Does your solution maintain an audit history of member status changes, and if
so, how far back?
35. Describe your solution’s ability to handle Low-Income Subsidy (LIS) and Late
Enrollment Penalty (LEP) reply codes.
a. Can your solution apply LIS codes so it generates the necessary LEP amount
communication(s)?
b. Can your solution adjust the premium based upon LIS and LEP?
36. What is your solution’s error correction process?
a. Does your solution support automated resubmission on error correction?
b. Describe any automated error correction components your solution supports
(e.g., based upon timing errors or based on information received from CMS?)
37. How does your solution communicate status changes back to the Plan’s
Membership System(s)?
15
38. Explain how your solution interfaces with other systems requiring status updates
of Medicare information.
39. Describe your ability to support increases in membership and work volume.
40. Should EON Health have all enrollment applications process to EON Health first
for initial screening, please describe how your organization could coordinate with
EON Health to receive and track the applications and the original receipt date.
41. Describe any processes that allow for EON Health’s sales staff to validate
Medicare entitlement and potential Medicaid entitlement.
G. Fulfillment/Mail Room Functions
1. Explain your fulfillment process; please be sure to include current service level
agreement time frames.
2. How are mail dates determined and stored?
3. How is inbound mail date/time-stamped, tracked, and triaged?
4. Describe the current output process, including but not limited to: ID cards, New
Member kits, Annual Notice of Changes (ANOC)/Evidence of Coverage (EOC),
member letters. Describe the identification and resolution of returned mail.
5. Provide an overview of Inventory Management (receipts, aging, and metrics) and
Quality Control (audit and performance management).
H. Member Reconciliation
1. Describe your solution’s reconciliation process for the TRR.
a. Describe the elements your solution can reconcile.
b. Describe any processing points that require manual intervention.
c. Does your solution allow a user to look up all TRR records for a specific
member? If so, please describe how.
2. Describe your solution’s reconciliation process for the Monthly Membership
Report (MMR).
a. Describe the elements your solution can reconcile.
b. Describe any processing points that require manual intervention.
c. Does your solution allow a user to look up all MMR records for a specific
member? If so, please describe how.
16
3. Describe your solution’s reconciliation process for the LIS/LEP report.
a. Describe the elements your solution can reconcile.
b. Describe any processing points that require manual intervention.
c. Can your solution create the LIS Acumen file?
4. Describe your solution’s reconciliation process for the Premium Withhold report.
a. Describe the elements your solution can reconcile.
b. Describe any processing points that require manual intervention.
5. Describe any other file(s) utilized in monthly member reconciliation. Explain the
identification, investigation, and resolution process of discrepancies.
6. Describe your membership reconciliation process and your interaction with CMS
on enrollment. Please provide specific examples of any direct CMS interaction,
including how reinstatement and retroactive processing is handled.
7. Can your solution support reconciliation between CMS data and your solution’s
Medicare records, then provide any discrepancies that could affect the payment
from CMS?
8. Describe how your solution updates CMS values. Include any CMS file imports,
any hierarchical relationship among the imports (e.g., order of import), and any
functionality your solution may provide to change a CMS value other than
through a CMS file import.
9. Files necessary for reconciliation:
a. List what CMS files your solution needs to import for the discrepancy
calculation process.
b. List what Plan files your solution needs to import for the discrepancy
calculation process.
10. As a Vendor, you will be required to support the MA plan with regard to the CMS
requirement to sign a membership enrollment attestation. Please describe your
experience and vision of this process.
11. Describe how your solution allows a user to flag a member as a "suspect" (e.g.,
End-Stage Renal Disease (ESRD), Hospice, Institutional) when no information
has been confirmed by a facility or physician, but the member still needs to be
tracked or managed until confirmed.
12. Describe your ability to coordinate membership reconciliation with a Pharmacy
Benefit Manager (PBM) in order to support a Medicare Advantage Prescription
Drug (MA-PD) product to be offered.
13. Describe your organization’s quality control program relative to the membership
reconciliation process.
14. Does your solution process “Other RX” and “other coverage information”?
17
a. If yes, what is your solution’s process for submitting RX coverage and other
coverage information?
i.
How does your solution handle the No RX from CMS and 4Rx to
CMS?
ii.
Does your solution support receiving and storing of Coordination of
Benefits (COB) data from Electronic Correspondence Referral
System (ECRS)?
15. Does your solution support storage of Other Health Insurance (OHI) data
including effective dates and history?
a. What is your solution’s logic for establishing primacy vs. secondary or
tertiary?
16. Describe any submission, tracking, and reporting process within your solution to
COB Contractor to correct erroneous Medicare Secondary Payer (MSP) records.
17. Describe how your solution loads, stores, displays, and makes available for
reporting and extracting CMS payments, including:
a. CMS payment and payment variables by member for month paid (detail).
b. CMS payment by Plan Benefit Package (PBP) and contract for month paid
(summary).
c. CMS payment and payment variables by member for month payment is for
(detail).
d. CMS payment by PBP and contract for month payment is for (summary).
18. What documentation do you provide to support the monthly reconciliation
attestation?
I. Financial Reconciliation
1. Can a user view all Plan and CMS payment variables for a member in one
summary page? Can a user view all discrepancies attributed to a member in one
summary page? If so, please attach a screen shot of a sample of each summary
page that your solution provides.
2. Describe the payment variables or discrepancies that have a submission process
to CMS Regional or Central Office within your solution.
3. Describe how your solution validates CMS payments based on CMS values and
on plan values for different data collection periods. Specify which results are
stored for viewing, reporting, and extracting and which are recalculated for each
access.
18
4. Describe how your solution handles differences between actual and expected
CMS payment amounts, on the member (detail) and PBP and contract
(summary) levels.
a. Are these differences calculated and stored, or recalculated each time they
are accessed?
b. What is the workflow to track and resolve the differences?
5. Describe how your solution handles missing or incorrect MMR data in payment
calculation.
6. Describe how your solution calculates revenue, at the detail and summary levels,
based on plan values for different data collection periods. Specify which results
are stored for viewing, reporting, and extracting, and which are recalculated for
each access.
7. Describe how your solution tracks the difference between receivables and
payables. What categorization (e.g., by membership, special status,
demographics, etc.) is provided or allowed by your solution? How does your
solution allow tracking and reporting of discrepancy resolution by category to
support trending analysis?
8. Describe the Part D calculations your solution performs, such as risk corridor
(including direct and indirect remuneration (DIR)), reinsurance, and LIS.
9. Describe your ability to complete Financial Information Reporting (FIR), True
Out-of-Pocket (TrOOP) balance transfer, and gross covered drug cost.
10. Describe what other supporting data your solution uses from external sources
(e.g., membership, plan). Specify what data is required and what is optional, and
what value the optional data would provide.
11. How is this supporting data entered into your solution (e.g., file formats, including
industry standard formats; workflow to import the data; what is automated and
what is manual; required and allowed frequency)? What validation is performed
and how are errors handled? If your solution requires or allows integration with a
risk adjustment submission solution (or other product), explain what data is
shared and how it is input (you may refer to previous answers, if appropriate).
12. Describe the process for Part D plan-to-plan payment and reconciliation within 30
days of enrollment in a new plan.
13. Describe the steps taken to ensure accurate reporting or rebates, refunds, and all
types of direct and indirect remuneration considered in CMS year-end Part D
financial settlement.
19
J. Premium Billing
1. Describe your system(s) generation of bills, collection tracking, and processing
capabilities. Include specific examples of delinquent and termination notices and
provide a sample of bill cycle time frames, from generation of original bill to
termination for non-payment of premium. Address Personal Health Information
(PHI) and HIPAA compliance requirements.
2. Describe the calculation of premiums (Bid, LEP, and LIS).
3. What billing options are available to individuals?
4. Describe online/web-based capabilities that provide billing information which can
be accessed by members and/or groups.
5. Describe your enrollment/billing system functionality that supports the
maintenance of multiple addresses for individual members (seasonal, snow
birds, etc.).
6. Describe the system(s)’s connectivity to enrollment and membership systems for
seamless processing of disenrollments.
K. Claims Submission, Adjudication, and Payment
1. Please give a complete description of your claims processing services and
system, with a specific focus on MA functionality. Include specific components
already constructed in your system for data exchanges with CMS and accepting
electronic claims.
2. Provide your median, mean, and 95% claims turnaround times, as well as other
relevant statistics. Describe your ability to comply with CMS’ requirement that
clean claims be paid within 30 days; your processes for following up on nonclean claims; and your ability to correctly calculate required interest for claims not
paid in a timely manner.
3. Describe your process for determining claims processing error rate and include
the claims accuracy performance for the past two years.
4. Describe your direct data entry capabilities.
5. Describe your current use of Medicare edits to adjudicate claims and your
capabilities to use Medicare edits for some services and customized edits for
other services.
6. Describe how you intend to incorporate Sponsor’s medical policy into the claims
payment process.
20
7. Describe the rework process for underpayments, recovery, and retroactive
changes, including subrogation and resolution of COB claims.
8. Describe any processes or edits you have in place to support accurate encounter
data submission to CMS for an MA plan.
9. Provide a description of the tracking and calculation of Maximum Out-of-Pocket
(MOOP), including Part B claims processed at the PBM.
10. Describe the current Output process, including but not limited to: Explanation of
Benefits (EOB), Remittance Advice (RA), Explanation of Payment (EOP), EDI,
Notice of Denial of Medicare Payment (NDMP) and Correspondence/letters.
11. Describe your available educational support for providers regarding claims data
coding to ensure accurate and timely payment.
12. Describe your ability to pay providers (check write) directly on behalf of the
Sponsors.
13. How are provider demographics maintained in the claims system including
identification of contracted versus non-contracted providers for payment?
14. Describe your process for paying out-of-network claims and your ability to
distinguish out-of-network claims from out-of-area claims (if required due to
benefit design.)
15. Are the CMS Program Audit Universe data files standardly able to be pulled from
vendor system?
L. Call Center – Customer Service and Provider Service functions will not be
delegated by Eon Health. Eon Health has existing software, but is
considering the use of vendor software for more effective interfacing.
Please respond to the below questions for software availability, at Eon
Health remote site.
1. Please describe the ability to allow Eon Health customer service and provider
service staff to utilize your member and provider call tracking systems.
2. Will Eon Health staff have access to view information for all delegated functions
and document calls within this system?
3. What challenges would this solution potentially cause?
21
4. What benefits would this solution potentially realize?
5. What ability does your software have to categorize calls and is it customizable?
6. What reporting options exist for call documentation for tracking and trending?
M. Appeals and Grievances. Eon Health is not delegating Appeals and
Grievance functions.
Please answer the below questions regarding
interfacing with Eon Health Staff.
1. Describe any processes currently in place for interfacing with a health plan that
has chosen not to delegate appeals and grievances.
2. Describe your process for providing any required information from the original
determination that is part of the appeal to the health plan.
3. Describe your process for identifying and redirecting any misdirected appeals or
grievances?
N. Medical Management – Eon Health will not be delegating Medical
Management. Processes will need to be set up so that Prior Authorizations
can be managed within vendor systems.
1.
Describe any processes currently in place for interfacing with a health plan that
has chosen not to delegate prior authorization functions.
2.
How would Eon Health staff be able tin interface with vendor’s Prior
Authorization system?
3.
How does Vendor’s system track expedited timeframes for date and time of
receipt and date, date and time of decision, and date and time of member
notification?
4.
What reporting is available within the system to track timelines?
5.
Are the CMS Program Audit Universe data files standardly able to be pulled
from vendor system?
22
O. Miscellaneous
1. Describe the assumptions your company would make regarding the time involved
with a typical implementation.
2. What assumptions are you making about the key roles, responsibilities, and
staff?
3. Would you subcontract some or all of the implementation?
4. What’s the total number of implementations you have done with your
operations/product(s) in the last 12 months?
5. If your company has the internal resources to implement the solution(s) for more
than one customer at a time, please describe your operating procedures and
priority scales during such concurrent implementations.
6. How would you ramp resources at the beginning, mid-way, and towards the end
of implementation?
7. What is the minimum skillset of employees needed for implementation? Give
your best estimate of the number and types of personnel needed to successfully
implement (i.e., on time, within well-planned budget parameters) your solution(s).
8. Provide professional service descriptions, including the number of years’
experience of the staff proposed for implementation.
23
24
Statement of Acknowledgement
I/We hereby acknowledge





Have read and understand the Eon Health Request for Proposal (RFP) and our
response adheres to all guidelines outlined in the Information Requirements of the
RFP.
May be disqualified from the RFP process if all the guidelines are not followed.
Acknowledge that I/We understand the information will form part of any future
contract with Eon Health.
Understand Eon Health reserves the right to do business with anyone at any time
for any reason without further notice to us.
Recognize neither Eon Health nor its agents, officers, and/or employees are liable
for any costs incurred by you, your directors, your officers, your employees, and/or
agents with respect to any aspect and/or stage of this RFP process.
Company Name:
______________________________
Applicant Name:
______________________________
Address:
______________________________
Director Name:
______________________________
Director’s Signature:
______________________________
Date:
______________________________
25