PART 755 PAYMENT OF ELIGIBLE CLAIMS OF SOIL AND WATER CONSERVATION DISTRICT EMPLOYEES UNPAID BY MID-CONTINENT MEDICAL BENEFIT TRUST : Sections Listing

TITLE 8: AGRICULTURE AND ANIMALS
CHAPTER I: DEPARTMENT OF AGRICULTURE
SUBCHAPTER q: SOIL AND WATER CONSERVATION
PART 755 PAYMENT OF ELIGIBLE CLAIMS OF SOIL AND WATER CONSERVATION DISTRICT EMPLOYEES UNPAID BY MID-CONTINENT MEDICAL BENEFIT TRUST

AUTHORITY: Implementing Section 6(11) of the Soil and Water Conservation Districts Act [70 ILCS 405] (see P.A. 90-565, effective January 2, 1998).

SOURCE: Adopted by emergency rule at 22 Ill. Reg. 2289, effective January 8, 1998, for a maximum of 150 days; adopted at 22 Ill. Reg. 9261, effective May 19, 1998.

 

Section 755.10  Preamble

 

The intent of Section 6(11) of the Soil and Water Conservation Districts Act [70 ILCS 405/6(11)] is to authorize the Illinois Department of Agriculture to pay health care costs of Soil and Water Conservation District employees incurred between January 1, 1996 and December 31, 1996 that were eligible for reimbursement from the District's insurance carrier, Mid-Continent Medical Benefit Trust, but were not paid by the carrier.

 

Section 755.20  Definitions

 

            "Administrator" means the professional third-party claims administrator chosen by the Department based on the criteria set forth in this Part to collect claims information and supporting documentation, and to provide recommendations to the Department.

 

            "Claim" means a request to the Department for payment of outstanding health care costs not previously reimbursed by Mid-Continent.

 

            "Department" means the Illinois Department of Agriculture.

 

            "District" means one of the Soil and Water Conservation Districts of Illinois.

 

            "Eligible Period" means the time period from January 1, 1996 through December 31, 1996.

 

            "Employee" means a person who was employed by a Soil and Water Conservation  District during the twelve month period from January 1, 1996 through December 31, 1996.

 

            "Mid-Continent" means Mid-Continent Medical Benefit Trust, the Districts' insurance carrier during the eligible period.

 

            "Outstanding Costs" means those health care costs for which employees were eligible for reimbursement from Mid-Continent, but which were not paid by Mid-Continent.

 

            "Provider" means any person or entity that provided health care services or products to an employee during the eligible period.

 

            "Valid Claim" means a claim that is verified and adjudged by the Department to be eligible for reimbursement.

 

Section 755.30  Validity of Claims

 

a)         For a claim to be adjudged valid, the employee shall submit documentation required by the Department which proves to the satisfaction of the Department that:

 

1)         The employee was covered by the District health insurance program offered through Mid-Continent during the eligible period;

 

2)         The health care for which payment is requested was provided during the eligible period;

 

3)         The health care costs claimed were eligible costs.

 

b)         The Department shall verify eligible costs claimed and shall determine the validity of all claims based on the recommendation of the Administrator.  The Department may reject all or portions of claims.

 

c)         Claims must have been submitted on or before Friday, January 30, 1998. Claims received after the close of business on January 30, 1998 will not be eligible for consideration.

 

Section 755.40  Procedures for Requesting Payment of Outstanding Costs

 

a)         Employees shall submit claims on forms provided by the Department. Employees shall provide documentation of:

 

1)         their policy's deductible amount and the amount of any payments applied toward it;

 

2)         the name, address, and telephone number of each provider for which outstanding costs are claimed;

 

3)         all outstanding costs claimed, including the date of service, patient account number, services provided and charges assessed;

 

4)         all payments made to providers or collection agencies against outstanding costs and the source of those payments; for example, the employee, secondary insurers, the Districts, other persons, etc.; and

 

5)         the amount of eligible costs, if any, which have been forgiven by the provider.

 

b)         Documentation acceptable to the Department shall include, but is not limited to, original provider bills, canceled checks, payment receipts, balance due statements, statements of benefits from Mid-Continent, and correspondence from providers, Mid-Continent or other relevant sources.

 

Section 755.50  Claims Processing

 

a)         In order to provide for the accurate and timely processing of claims, the Department will secure the services of a professional administrator.  The Administrator will be selected based on criteria elaborated in Exhibit A of this Part including:

 

1)         qualifications;

 

2)         ability to perform vendor responsibilities;

 

3)         technical capabilities;

 

4)         certifications; and

 

5)         cost.

 

b)         All claims and supporting documentation will be verified by the Administrator.  The Administrator may request from employees any additional documentation the Administrator deems necessary to process and verify claims.  The Department will determine the validity of claims based upon recommendations from the Administrator.

 

Section 755.60  Payment by the Department

 

a)         Before issuing payment for valid claims, the Department shall require the payee and the employee, if the two are not the same, to sign and submit:

 

1)         a subrogation agreement.  The agreement will be provided by the Department and will assign to the Department the proceeds of any future recovery action that may be initiated regarding the claims being paid; and

 

2)         a release acknowledging payment in full and releasing the Department from any future responsibility to pay.

 

b)         Upon receipt of all signed agreements, the Department will issue a payment voucher for the amount of approved outstanding costs.

 

c)         The Department will not pay any interest, late fees or similar penalties charged to the employee by any provider or credit agency.



Section 755.EXHIBIT A   Request for Proposal

 

THE STATE OF ILLINOIS DEPARTMENT OF AGRICULTURE IS REQUESTING PROPOSALS TO FILL THE STATE'S NEEDS AS OUTLINED BELOW.  PLEASE READ THIS ENTIRE PACKAGE AND SUBMIT PROPOSAL IN ACCORDANCE WITH THESE INSTRUCTIONS.

 

DESCRIPTION OF GOODS OR SERVICES

 

PROFESSIONAL ADVICE AND CLAIMS ADJUDICATION RECOMMENDATIONS FOR THE PAYMENT OF OUTSTANDING HEALTH CARE COSTS OF SOIL AND WATER CONSERVATION DISTRICT EMPLOYEES THAT WERE ELIGIBLE FOR REIMBURSEMENT FROM THE DISTRICTS' INSURANCE CARRIER, MID-CONTINENT MEDICAL BENEFIT TRUST.

 

SEND PROPOSALS TO:

 

IDENTIFY PROPOSAL AS:

 

ILLINOIS DEPARTMENT OF AGRICULTURE

CHIEF, BUREAU OF LAND AND WATER RESOURCES

STATE FAIRGROUNDS

P.O. BOX 19281

SPRINGFIELD, ILLINOIS   62794-9281

CLAIMS ADJUDICATION PROPOSAL

 

PROJECT CONTACT:

 

CHIEF, BUREAU OF LAND AND WATER RESOURCES

PHONE: 217-782-2172

TDD:   1-800-524-6858

 

SUBMIT A SIGNED ORIGINAL AND 3 COPIES OF YOUR PROPOSAL IN A SEALED CONTAINER.

 

PROPOSAL DUE

 

 

This package consists of:  Instructions; General Information; Basic Contract Terms and Conditions; Detailed Specifications; Technical Proposal; Intent to Propose.

 

EFFECTIVE IMPLEMENTATION DATE IS IMMEDIATE UPON SELECTION.


REQUEST FOR PROPOSAL

 

 

 

Claims Adjudication Services

for

Payment of Outstanding Health Care Costs

 

 

Administered by

 

 

Illinois Department of Agriculture

 

 

Issued by

 

State of Illinois

Illinois Department of Agriculture

Bureau of Land and Water Resources

 

Becky Doyle

 

Director

 

 

TABLE OF CONTENTS

 

Section I

Bidding Process

 

Section II

Contract Terms and Conditions

 

Section III

Minimum Qualifications

 

Section IV

Background

 

Section V

Department and Vendor Responsibilities

 

Section VI

Technical Proposal

 

Section VII

Proposal Submittal Requirements

 

Section VIII

Certifications

 

CLAIMS ADJUDICATION PROPOSAL


Section I

Bidding Process

 

1.1       Type of Process

 

In the RFP process the Department intends to make an award to the responsible Vendor(s) whose proposal is determined to provide the best value to the Department.  The Department's needs are well defined, and the responses will be evaluated in accordance with predetermined criteria.  Although the evaluation may result in a need to clarify proposals or to request "best and finals" from those in the zone of contention, the proposal as submitted will generally be the basis upon which a decision to award is made.

 

A response to this RFP will be referred to as a proposal.

 

1.2       Submission of Proposals

 

The date, time and address for submitting proposals are shown on the instructions page.  Please follow these directions carefully.  Failure to comply is cause for rejection of the proposal.

 

Proposals, including amendments, may be mailed or hand delivered; but in either case, must be actually received as specified.  Proposals received late will be returned unopened.

 

Proposals must be submitted in typed or printed form. Each original proposal and each of the copies must be signed in ink by an authorized representative of the Vendor.  Amendments shall be signed by the same person who signed the proposal unless another person has been given signature authority, which must be verified.

 

The following describes the format in which bid proposals must be presented.  Utilization of a standard format will facilitate the evaluation process.  Each proposal must contain, at a minimum, the following items and must be presented in the following sequence:  (Please provide the level of detail requested.)

 

A.        Agreement to Contract Terms and Conditions (Section II)

B.        Qualifications Documentation (Section III) with signed Certifications (Section VIII)

C.        State and Vendor Responsibilities (Section V)

D.        Technical Proposal - Questionnaire and Responses (Section VI)

 

NOTE:            Price information must be submitted in a separate envelope within the sealed container.  Price information is not to be shown in any other part of the proposal.

 

1.3       Proposal Reservations

 

The Department reserves the right to reject any or all proposals, to request and evaluate "best and final" proposals, to award in whole or in part, and to waive minor defects.  An individual proposal may be rejected if it fails to meet any requirement.  The Department may seek clarification from a Vendor at any time, and failure to respond is cause for rejection.  Any alternate proposal that meets the Department's needs may also be considered.  Contract negotiations may be necessary after the award to formalize understandings.

 

Submission of a proposal confers no rights on the Vendor to an award or to a subsequent contract.  This RFP process is for the Department's benefit only and is intended to provide the Department with competitive information to assist in selection of goods or services.  All decisions on compliance, evaluation, terms, and conditions shall be made solely at the Department's discretion and made to favor the Department.

 

The Department reserves the right to modify requirements during the course of this contact by changing the scope of work, deliverables, and time frames, as well as addition or deletion of tasks to be performed or equipment to be provided and/or any other modification deemed necessary.  Any changes in pricing proposed by the Vendor resulting from the proposed changes will be subject to acceptance by the Department.  In the event prices are not acceptable to the Department, the contract may be subject to reprocurement based upon the new specifications.

 

1.4       Inquiries

 

Any inquiries shall be directed to the project contact.  Do not discuss the proposal with any other State employee unless authorized by the project contact.  All responses by the Department must be in writing to be binding.

 

1.5       Non-Conforming Technical Proposals

 

To be considered, the Vendor must submit a definitive proposal, as requested by this solicitation, for the work to be accomplished under the proposed contract.  Proposals which merely offer to conduct a program in accordance with the general requirements of the RFP may be considered non-conforming and may not be considered.

 

1.6       Cost of Proposal Preparations

 

All costs associated with preparation and submission of a proposal are the responsibility of the Vendor.  These costs shall not be chargeable to the Department by the successful or unsuccessful Vendors.

 

All proposals become the property of the Department and will not be returned except in the case of a late submission.

 

1.7       Right to Contract

 

This RFP does not commit the Department to award a contract or to pay costs incurred in the submission of proposals, or costs incurred in making necessary studies for the preparation thereof, or to procure or contract for services or supplies.  The Department reserves the right to reject any or all proposals, to negotiate with any Vendor(s) considered qualified, or to make award without further discussions.

 

1.8       Responsibility

 

In determining whether a Vendor is responsible, the Department will evaluate past performance, financial stability, references, compliance with applicable laws, business ethics and integrity, the perceived ability to perform completely as specified, and other relevant factors. Vendor must submit a current audited financial statement, annual or quarterly report, Dunn & Bradstreet rating or other acceptable proof of financial responsibility, and any other information to prove responsibility with the proposal to the address shown below.  Additional information may be requested.  Financial responsibility will be kept confidential unless otherwise required by law.

 

Illinois Department of Agriculture

Chief, Bureau of Land and Water Resources

State Fairgrounds

P.O. Box 19281

Springfield, Illinois   62794-9281

 

1.9       Evaluation

 

The Department will evaluate each response to the proposal using predetermined evaluation criteria.  The general evaluation criteria, point ranking, formula, etc. will be disclosed to Vendors upon request, unless it is determined that disclosure could result in bias.

 

1.10     Best and Final

 

The Department's evaluation process includes the use of "best and final" proposals when deemed appropriate.  The Department reserves the right, at any time prior to award of a contract and for any reasons, to request and consider "best and final" proposals from one or more of the Vendors who submitted a proposal.  The number of Vendors allowed to submit "best and final" proposals and the scope of the "best and final" proposals shall be determined solely by the Department.  No Vendor has a right to submit a "best and final."  Any Vendor who is asked and fails to submit a "best and final" proposal need not be given further consideration.  The purpose of the "best and final" proposal is to allow the Department to better define its needs; adjust specifications or other aspects of the procurement to reflect changed needs or perceptions or to address problems; or for any other purpose deemed appropriate by the Department.

 

1.11     Award

 

The Department will select the proposal(s) which meets the Department requirements and provides the best value to the Department, price and other factors being considered, and which is submitted by a responsible Vendor(s). The Department reserves the right to award to multiple Vendors.  All awards must be approved by the Department.

 

1.12     Contract Negotiations

 

The Vendor(s) chosen for an award may be required to enter into contract negotiations with the Department.  The Vendor(s) should be prepared to incorporate the Department request and the Vendor's proposal and any other written representations submitted with the proposal.  If agreement cannot be reached to the Department's satisfaction, negotiations may begin with another Vendor(s). All contracts must be approved by the Department.

 

1.13     Commencement of Work

 

The successful Vendor(s) must not commence any billable work prior to the Department's execution of the contract.  Work done before final execution is at the Vendor's risk.

 

1.14     Vendor Contact

 

Each Vendor shall designate one person who shall serve as contact for all matters pertaining to the proposal.  In absence of such designation, the person who signs the proposal shall be deemed the Vendor contact.

 

1.15     Assignment/Subcontracting/Joint Ventures

 

Each entity the Department contracts with shall be contractually responsible for the total performance of its contract.  Assignments for financing and subcontracting are allowable, but information on assignees and subcontractors must be provided.  For any joint venture to be acceptable, one Vendor must take full contractual responsibility for performance.  No assignment, subcontract, or joint-venture shall operate to increase any obligation.  If a subcontractor is used to provide consulting services, the subvendor's name and amounts paid to the subcontractor must be disclosed.

 

1.16     Governing Law

 

This RFP and any subsequent contract shall be governed by the laws and rules of the State of Illinois which are incorporated into this RFP by reference.

 

Section II

Contract Terms and Conditions

 

The following terms and conditions are applicable to State Contracts. Negotiations may be necessary to further define these and other terms. Submission of a signed response to this solicitation indicates agreement to the terms and conditions contained herein, unless Vendor indicates an exception in writing.

 

2.1       Payment Responsibility

 

The Department will make payments to the Vendor(s) in accordance with specified terms and conditions of the contract.

 

2.2       Fiscal Funding

 

Obligations of the Department shall cease immediately and without penalty or further payment being required if in any fiscal year the Illinois General Assembly or federal funding source fails to appropriate or otherwise make available appropriate funds for this contract.

 

2.3       Conflict of Interest

 

A.        Vendor(s) must identify each individual having a beneficial interest in the business which exceeds 7½%.

 

B.        The conflict of interest provisions of the Illinois Purchasing Act generally prohibit contracting with a State employee or an employee's spouse or minor child; or with Vendor if any State employee is entitled to receive either directly or indirectly more than 7½%, or together with spouse and/or minor children more than 15%, of the total distributable income of the business. If any individual has such a prohibited interest, that fact must be disclosed as a part of the proposal and the Vendor must state why the prohibition should not apply.  The Department will determine whether an exemption to the general prohibition will be allowed.

 

2.4       Nondiscrimination

 

The Vendor, his employees, and subcontractors agree not to commit unlawful discrimination and agree to comply with applicable provisions of the Illinois Human Rights Act, the U.S. Civil Rights Act, Section 504 of the Federal Rehabilitation Act, and rules applicable to each.  The Department of Human Rights' equal opportunity clause is specifically incorporated herein.

 

In compliance with the State and federal constitutions, the Illinois Human Rights Act, the U.S. Civil Rights Act, Section 504 of the Federal Rehabilitation Act, the Department of Agriculture does not unlawfully discriminate in employment, contracts, or any other activity.

 

The Americans with Disabilities Act (42 U.S.C. 12101 et seq.) and the regulations thereunder (28 CFR 35.130) (ADA) prohibit discrimination against persons with disabilities by the Department, whether directly or through contractual arrangements, in the provisions of any aid, benefit or service.  As a condition of receiving this contract, the undersigned Vendor certifies that services, programs and activities provided under this contract are and will continue to be in compliance with the Americans with Disabilities Act (ADA).

 

2.5       Liability and Insurance

 

The Department does not assume any liability for acts or omissions of the Vendor, and such liability rests solely with the Vendor.  The Vendor shall carry public liability, casualty, and auto insurance in sufficient amount to protect the Department from liability for acts of the Vendor. In addition, the Vendor shall carry worker's compensation insurance, if applicable, in the amount required by law.

 

2.6       Hold Harmless and Indemnification Agreement

 

The Vendor shall save and hold harmless and indemnify the Department against any and all liability, claims, and costs of whatever kind and nature for injury to or death of any person or persons and for loss or damage to any property occurring in connection with or in any way incident to or arising out of the use, service, operation, or performance of work under the terms of this contract resulting from the negligent acts or omissions of vendor, of any employee, agent, or representative of Vendor or subvendor.  The Vendor is not responsible for consequential damages.

 

2.7       Limited Distribution or Use of Certain Data and Information

 

Vendor agrees that Vendor personnel will not divulge or release data or information developed or obtained in connection with the performance of the contract, unless made public by the Department, except to authorize Department personnel or upon written approval of the user agency's project manager.

 

2.8       Disposition of Records

 

Within 30 days of receiving notice from the Department, the Vendor will provide to the Department all records related to processing and validating claims and making its recommendations to the Department.  Failure to maintain the books, records, and supporting documents required by this Section shall establish a presumption in favor of the Department for the recovery of any funds paid by the Department under the contract for which adequate books, records, and supporting documentation are not available to support their purported disbursement.

 

2.9       Sexual Harassment

 

Effective July 1, 1993, the Vendor or Vendors shall have written sexual harassment policies that shall include, at a minimum, the following information: (i) the illegality of sexual harassment; (ii) the definition of sexual harassment under State law; (iii) a description of sexual harassment, utilizing examples; (iv) the Vendor's internal complaint process including penalties; (v) the legal recourse, investigative and complaint process available through the Department of Human Rights and the Human Rights Commission; (vi) directions on how to contact the Department and Commission; and (vii) protection against retaliation as provided by Section 6-101 of the Illinois Human Rights Act.  A copy of the policies shall be provided to the Department upon request.

 

2.10     Breach

 

Any breach of this contract by the Vendor will allow the Department to cancel without penalty and have any other available relief.

 

2.11     Governing Law

 

This contract shall be governed by the laws and rules of the State of Illinois which are incorporated into this RFP by reference.

 

Section III

Minimum Qualifications

 

In order for a Vendor to qualify to submit information and a proposal, it should be able to meet all of the following, or the equivalent of such requirements.  It is at the discretion of the Department to determine the extent to which the following qualifications are required for award of the contract or that failure to meet these qualifications may disqualify any Vendor.  The Department intends to evaluate each proposal in its entirety.

 

In order for a Vendor to qualify to submit a proposal for Claims Administration Services, the following minimum qualifications must be met:

 

•           Licensure/Certification.  The Vendor must be licensed or registered with the Illinois Department of Insurance as a third party administrator as required by applicable Illinois law.

 

•           Experience.  The Vendor must have a minimum of two years of satisfactory experience in claims administration.

 

•           Financial Condition.  The Vendor must demonstrate sound financial condition and good business practices.  Accounting methods must maintain a clear distinction between claims administration performed under contract for the Department and other business.

 

•           Reports. The Vendor must agree to furnish the Department with timely reports in mutually agreed upon formats.

 

•           Customer Service/Communications.  The Vendor must provide a telephone number for claims inquiries which will be available to all employees during regular business hours.

 

•           Medical Review.  The Vendor must have medical professionals with appropriate credentials to review questionable claims.  Medical experts must be present for final review/fact-finding meetings at the request of the Department.

 

•           Pricing Screens.  The Vendor must have available and provide on request all pricing screens and maximum allowable reimbursement levels per procedure code, provider, and service.

 

•           Background Check.  As a condition of award and as a continuing condition of any resulting contract, the Department reserves the right to conduct background checks of Vendor, its officers, and of those employees or agents who would perform the required services to determine suitability for performing this contract.  Vendor shall complete or have completed an authorization for release of personal information that indemnifies both the Department and the provider of the information.

 

Section IV

Background

 

The Department is requesting proposals for claims administration services to assist the Department in carrying out responsibilities pursuant to 70 ILCS 405/6(11) regarding the payment for outstanding health care costs of Soil and Water Conservation District employees.  Soil and Water Conservation District employees, their dependents, and spouses had health care coverage provided by Mid-Continent Medical Benefit Trust (Mid-Continent).  In late 1995, Mid-Continent developed financial difficulties that ultimately resulted in the non-payment of claims for provider services estimated to be in excess of $172,000.  The Department has been granted legal authority to pay these outstanding health care costs and is seeking a qualified Vendor(s) to determine the amount of each claim to be paid based on standard claims adjudication practices.

 

CONTRACT:

 

This contract will be effective through ___________.  The contract between the Department and the Vendor will detail the services included in the administrative services fees proposed.  Any additional services provided will be separately identified and negotiated.

 

Section V

Department and Vendor Responsibilities

 

The following are Department and Vendor responsibilities as indicated, applicable to any contract that may be offered as a result of this proposal. Indicate understanding and acceptance of each of the following:

 

DEPARTMENT RESPONSIBILITIES:

 

The Department will perform the following functions:

 

1.         Provide a copy of the Mid-Continent Medical Benefit Trust document, and names, addresses, and phone numbers of the business entities relevant to the agreement.

 

2.         Verify that claimants were eligible for insurance coverage through the Mid-Continent Medical Benefit Trust document provided by Mid-Continent  during the period January 1, 1996 through December 31, 1996.

 

3.         Provide list of verified eligible claimants.

 

4.         Provide all initial claims information submitted by employees and providers to Vendor.

 

5.         Make final decision on validity of claims based upon supporting documentation furnished by the Vendor.

 

6.         Receive Explanation of Benefits (EOB) from Vendor and include the EOB with payments made on valid claims.

 

VENDOR RESPONSIBILITIES:

 

The Vendor will perform the following functions:

 

A.        Receive initial claims information directly from the Department and obtain additional information necessary to adjudicate claims and make recommendations from employees or providers;

 

B.        Make recommendations to the Department including supporting documentation on the validity of claims and the amount of payment to which employee is entitled under the terms with Mid-Continent;

 

C.        Coordinate benefit coverages for covered individuals;

 

D.        Upon final determination by the Department that a claim is valid, issue explanation of benefits to the Department (including copies for custodial parents) on the disposition of each claim submitted;

 

E.         Maintain timeliness, comprehensive auditing and internal quality control procedures;

 

F.         Respond to written and telephone inquiries;

 

G.        Provide actuarial, medical and legal advice related to benefits determinations;

 

H.        Make periodic reports to Department as required;

 

I.          Meet with representatives of the Department at Department's request;

 

J.          Have a fraud prevention and control plan in place;

 

K.        Agree to cooperate in any transfer of functions from one Vendor to another Vendor;

 

L.         Within 30 days of receiving notice from the Department, provide all records to the Department that contain information used by the Vendor to process and adjudicate claims and make recommendations.

 

Section VI

Technical Proposal

 

Please address each of the issues in full detail in the order below, repeating the question, followed by the response.

 

A.        Organizational History and Structure

 

1.         Provide a copy of the latest financial statement submitted to the State of Illinois Department of Insurance and/or the latest annual report.

 

2.         Name all financial interests in the organization and explain the relationship(s).

 

3.         List the proposed service team for this account.

 

4.         When did the organization begin providing the services which are proposed?  List 5 clients for which the organization provided similar services.  Include contact name and phone number.  What is the total volume of claims payments and the amount of transaction fees?

 

5.         From what location(s) would the Department's account be managed and serviced?

 

6.         Has the organization been sued in the last five years?  Describe any lawsuits and their resolution.

 

B.        Claims Processing

 

The primary responsibility of the Vendor is to process claims accurately and in a timely manner after the Department has furnished eligibility information. The Vendor will be expected to receive all claims directly from the Department, obtain supplemental information as needed to process claims, recommend to the Department the amount to be paid, and issue an EOB to the Department.  The Department will mail the EOB along with the check to the applicable Soil and Water Conservation District.

 

1.         List and describe all services included in the proposed claims processing fees.

 

2.         Describe all claims processing procedures from receipt of claim form including:

 

a.         Preparation of claims for processing

b.         Coordination of benefits

c.         Claimant/provider communications

d.         Claim edits, including reasonable and customary charge edits

e.         Explanation of benefits with samples

f.          Responding to employee inquiries

 

3.         Specify how reasonable and customary determinations are developed, by whom, for which services, how often screens are updated, and the process for approval of charges above the levels set.

 

4.         Describe coordination of benefits procedures.

 

5.         Provide samples of explanations of benefits, inquiry letters, and all other communication pieces that would be used with claims processing.

 

6.         What are the criteria and what percentage of claims are reviewed by a medical professional?

 

7.         What internal controls are in place to ensure quality and accuracy?

 

C.        Systems Capabilities

 

1.         Describe the edits to be used to assure accuracy and proper payment of claims.

 

D.        Financial Arrangements

 

1.         Describe procedures established to detect and control fraud.

 

2          Give a step-by-step description of the recovery process and the reporting for each of the following instances:

 

a.         fraudulent claim submitted by a provider or an employee

b.         subrogation case

c.         retroactive change in membership

d.         Vendor employee fraud

 

E.         Customer Service

 

Describe the customer service function that will be included in this Contract.

 

F.         Reporting

 

Provide a final report listing all claims processed and/or any other reports deemed necessary by the Department within 30 days of expiration of the Contract between the Department and the Vendor.

 

Section VII

Proposal Submittal Requirements

 

The purpose of these specifications is to provide relevant information to Vendors interested in submitting proposals to make recommendations on the adjudication of claims pursuant to the authority granted under 70 ILCS 405/6(11) concerning the payment for outstanding health care costs of Soil and Water Conservation District employees.

 

Objectives in Soliciting Proposals:

 

The Department has two primary objectives in soliciting proposals for claims processing:

 

•           to obtain professional advice and claims adjudication recommendations;

•           to obtain these services at a competitive cost.

 

General Submission Guidelines:

 

The date, time and address for submitting proposals are shown on the instructions page of the Request for Proposal.  Please follow these directions carefully.  Failure to comply is cause for rejection of the proposal. Proposals, including amendments, may be mailed or hand delivered; but in either case, must be actually received as specified.  Proposals received late will be returned unopened.

 

Bidders will be required to present the data required by this RFP in an organized format which includes the minimum Qualifications (and signed Certifications), the Technical Proposal (and References) and the Fee Quotation.  Utilization of a standard format will facilitate the evaluation.  Bidders must present complete and self-explanatory information as required by this RFP. Information provided by Vendors will first be reviewed for minimum qualifications.  Vendors meeting the minimum requirements will be further evaluated using the content of the Technical Proposal, based on its completeness and scope.  The fee quotation will be reviewed after potential Vendors have been evaluated for overall quality and service level proposed.

 

Proposal Components:

 

To be considered for selection, a signed original and three (3) copies of sealed proposals must be submitted in a format organized by three major sections:

 

•           Minimum Qualifications documentation (and signed Certifications)

•           Responses to questions in the Technical Proposal and References

•           Fee Quotation

 

Minimum Qualifications Documentation:

 

This section of the proposal should provide all pertinent licensure, registration, and experience information.  The official corporate position on each of the qualifications listed should be stated.  Any deviation from the qualifications should be clearly identified and alternatives suggested for the Department's consideration.

 

Certifications:

 

A copy of the Certifications section should be completed and submitted with the proposal.  An original signature(s) must appear on the last page of the completed Certifications section.

 

Technical Proposal:

 

The Technical Proposal is to be organized in a sequence to follow the order of the major topics of Section VI of this RFP.  Please repeat the question, followed by the appropriate response.  The Technical Proposal should contain descriptions of how the prospective Vendor intends to service the account.

 

References should be provided as the final part of the Technical Proposal.

 

Fee Quotation:

 

Three copies of the fee quotation must be submitted in a separate sealed envelope.  Specify any additional fees applicable.  Please identify the service and the associated charges.

 

Supplemental Information:

 

The response to the RFP must be received by the Department by 5:00 p.m. C.S.T., _________. Send the response to:

 

Illinois Department of Agriculture

Chief, Bureau of Land and Water Resources

State Fairgrounds

P.O. Box 19281

Springfield, Illinois   62794-9281

 

Section VIII

Certifications

 

I.          The Vendor certifies that it is not barred from being awarded a contract or subcontract under Section 10.1 or 10.3 of the Illinois Purchasing Act (30 ILCS 505/10.1 and 10.3).

 

II.        The Vendor certifies that it has not been barred from contracting with a unit of State or local government as a result of a violation of Section 33-E3 or 33-E4 of the Criminal Code of 1961 (720 ILCS 5/33E-3, 5/33E-4).

 

III.       The Vendor certifies that it is not in default on an educational loan as provided in Public Act 85-827 (5 ILCS 385) (a partnership shall be considered barred if any partner is in default on an education loan).

 

IV.       The Vendor certifies that it does not pay dues or fees on behalf of its employees or agents, nor subsidizes or otherwise reimburses them for payment of their dues or fees, to any club which unlawfully discriminates (775 ILCS 25).

 

V.        Under penalties of perjury, I certify that the name, taxpayer identification number, and legal status listed below are correct.

 

Name:

 

 

Taxpayer Identification Number:

Social Security Number

 

or

Employer Identification Number

 

 

(If you are an individual, enter your name and SSN as it appears on your Social Security Card.  If completing this certification for a sole proprietorship, enter the owner's name followed by the name of the business and the owner's SSN.  For all other entities, enter the name of the entity as used to apply for the entity's EIN and the EIN.)

 

Legal Status (check one):

Individual

Governmental entity

Ownership of Sole Proprietorship

Nonresident alien individual

Partnership

Estate or legal trust

Tax-exempt hospital or extended care facility

Foreign corporation, partnership, estate or trust

Corporation providing or billing medical and/or health care services

Other

Corporation NOT providing or billing medical and/or health care services

 

 

 

VI.       This certification is required by the Drug Free Workplace Act (30 ILCS 580) for contracts and grants effective January 1, 1992, and thereafter.  The Drug Free Workplace Act requires that no grantee or vendor shall receive a grant or be considered for the purposes of being awarded a contract from the State for the procurement of any property or services unless that grantee or vendor will provide a drug free workplace, and that individuals must not engage in the unlawful manufacture, distribution, dispensation, possession or use of a controlled substance in the performance of the contract or grant.  False certification or violation of the certification may result in sanctions including, but not limited to, suspension of contract or grant payments, termination of the contract or grant and debarment of contracting or grant opportunities with the State for at least one (1) year but not more than five (5) years.

 

Vendor/Grantee:  For the purpose of this certification, "grantee" or "vendor" means a corporation, partnership, or other entity with twenty-five (25) or more employees at the time of issuing the grant, or a department, division, or other unit thereof, directly responsible for the specific performance under a contract or grant of $5,000 or more from the State.

 

The vendor/grantee certifies and agrees that it will provide a drug free workplace by:

 

(a)        Publishing a statement:

 

(1)       Notifying employees that the unlawful manufacture, distribution, dispensation, possession, or use of a controlled substance, including cannabis, is prohibited in the grantee's or vendor's workplace.

 

(2)       Specifying the actions that will be taken against employees for violations of such prohibition.

 

(3)       Notifying the employee that, as a condition of employment on such contract or grant, the employee will:

 

(A)      abide by the terms of the statement; and

 

(B)       notify the employer of any criminal drug statute conviction for a violation occurring in the workplace no later than five (5) days after such conviction.

 

(b)        Establishing a drug free awareness program to inform employees about:

 

(1)        the dangers of drug abuse in the workplace;

 

(2)        the grantee's or vendor's policy of maintaining a drug free workplace;

 

(3)        any available drug counseling, rehabilitation, and employee assistance programs; and

 

(4)        the penalties that may be imposed upon employees for drug violations.

 

(c)        Providing a copy of the statement required by subparagraph (a) to each employee engaged in the performance of the contract or grant and posting the statement in a prominent place in the workplace.

 

(d)       Notifying the contracting or granting agency within 10 days after receiving notice under part (B) of paragraph (3) of subsection (a) above from an employee or otherwise receiving actual notice of such conviction.

 

(e)        Imposing a sanction on, or requiring the satisfactory participation in a drug abuse assistance or rehabilitation program by, any employee who is so convicted, as required by section 5 of the Drug Free Workplace Act.

 

(f)        Assisting employees in selecting a course of action in the event drug counseling, treatment, and rehabilitation are required and indicating that a trained referral team is in place.

 

(g)        Making a good faith effort to continue to maintain a drug free workplace through implementation of the Drug Free Workplace Act.

 

Individuals:  If Vendor is an individual, or an individual doing business in the form of a sole proprietorship, the individual certifies that the individual will not engage in the unlawful manufacture, distribution, dispensation, possession or use of a controlled substance in the performance of the contract.  Vendor certifies that it will not engage in the unlawful manufacture, distribution, dispensation, possession or use of a controlled substance in the performance of the contract.  This requirement applies to contracts of more than $5,000.

 

VII.     Non-discrimination:  In compliance with the State and Federal Constitutions, the Illinois Human Rights Act, the U.S. Civil Rights Act, and Section 504 of the Federal Rehabilitation Act, the Department of Agriculture does not unlawfully discriminate in employment, contracts, or any other activity.

 

Vendor, its employees and subcontractors, agree not to commit unlawful discrimination and agree to comply with applicable provisions of the Illinois Human Rights Act, the Public Works Employment Discrimination Act, the U.S. Civil Rights Act and Section 504 of the Federal Rehabilitation Act, and rules applicable to each.  The equal employment opportunity clause of the Department of Human Rights rules is specifically incorporated within this RFP.

 

The Americans with Disabilities Act (42 U.S.C. 12101 et seq.) and the regulations thereunder (28 CFR 35.130) (ADA) prohibit discrimination against persons with disabilities by the State, whether directly or through contractual arrangements, in the provision of any aid, benefit or service.  As a condition of receiving this contract, the undersigned Vendor certifies that services, programs and activities provided under this contract are and will continue to be in compliance with the ADA.

 

VIII.    Early Retirement.  Vendor certifies he/she has informed the Director of the Department of Agriculture in writing if he/she was formerly employed by the Department of Agriculture and has received an early retirement incentive under Section 14-108.3 or 16-133.3 of the Illinois Pension Code.  Vendor acknowledges and agrees that if such early retirement incentive was received, this contract is not valid unless the official executing the contract has made the appropriate filing with the Auditor General prior to execution.

 

IX.       Retention of Records:  The Vendor shall maintain, for a minimum of five years after the completion of the contract, adequate books, records, and supporting documents to verify the amount, recipients, and uses of all disbursements of funds passing in conjunction with the contract; the contract and all books, records, and supporting documents related to the contract shall be available for review and audit by the Auditor General; and the vendor agrees to cooperate fully with any audit conducted by the Auditor General and to provide full access to all relevant materials.  Failure to maintain the books, records, and supporting documents required by this Section shall establish a presumption in favor of the State for the recovery of any funds paid by the State under the contract for which adequate books, records, and supporting documentation are not available to support their purported disbursement.

 

X.        Sexual Harassment:  Effective July 1, 1993, the Vendor shall have written sexual harassment policies that shall include, at a minimum, the following information:  (i) the illegality of sexual harassment; (ii) the definition of sexual harassment under State law: (iii) a description of sexual harassment, utilizing examples; (iv) the vendor's internal complaint process including penalties; (v) the legal recourse, investigative and complaint process available through the Department of Human Rights and the Human Rights Commission; (vi) directions on how to contact the Department and Commission; and (vii) protection against retaliation as provided by Section 6-101 of the Illinois Human Rights Act.  A copy of the policies shall be provided to the Department upon request.

 

XI.       For contracts exceeding $10,000, the Vendor certifies that neither it nor any substantially-owned affiliated company is participating or shall participate in an international boycott in violation of the provisions of the U.S. Export Administration Act of 1979 or the regulations of the U.S. Department of Commerce promulgated under that Act.

 

The undersigned acknowledges and agrees that each of the certifications or amendments shall be incorporated into and made a part of the invitation for bids, request for proposals, agreement, contract, amendment, renewal or other similar document to which these certifications are attached.

 

VENDOR

NAME

 

BY

 

TITLE

 

 

PROPOSAL COVER SHEET

CLAIMS ADJUDICATION PROPOSAL

 

Submitted by:

 

Firm

By

Title

Signature

Date

Telephone Number

Toll-free Number

Fax Number

 

RETURN A SIGNED ORIGINAL AND THREE (3) COPIES OF PROPOSAL TO:

 

State of Illinois

Department of Agriculture

Chief, Bureau of Land and Water Resources

State Fairgrounds

P.O. Box 19281

Springfield, Illinois   62794-9281

 

PROPOSAL DUE: