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FBO DAILY - FEDBIZOPPS ISSUE OF APRIL 17, 2015 FBO #4892
SOURCES SOUGHT

Q -- RSAF Medical Insurance Administration Services

Notice Date

4/15/2015
 

Notice Type

Sources Sought
 

NAICS

524114 — Direct Health and Medical Insurance Carriers
 

Contracting Office

AFICA - AFICA- CONUS
 

ZIP Code

00000
 

Solicitation Number

FA3002-15-RFI-RSAF_Medical_Insurance
 

Point of Contact

Kenneth McCright, Phone: 210-652-9093
 

E-Mail Address

kenneth.mccright.3@us.af.mil
(kenneth.mccright.3@us.af.mil)
 

Small Business Set-Aside

N/A
 

Description

PURPOSE: The 338th Specialized Contracting Squadron (338 SCONS) is seeking information concerning the availability of potential sources for Medical Administration Services in support of the Royal Saudi Air Force (RSAF). Based on the following information, the goal of this Request for Information (RFI) is to determine the number of potential sources available to provide Medical Administration Services per the Statement of Objectives (SOO) below. NOTE: This RFI is issued for informational and planning purposes only. This information will be used as part of market research to identify qualified, experienced, and interested potential sources in support of this requirement. Contact with Government personnel, other than those specified in this RFI, by potential offerors or their employees' regarding this requirement is not permitted. This is not a RFP. It is not to be construed as a formal solicitation or an obligation on the part of the Government to acquire any products or services. Any information provided to the Government is strictly voluntary and will be provided at no cost to the Government. For purposes of this RFI, the North American Industry Classification System (NAICS) Code is 524114 (Direct Health and Medical Insurance Carriers), with a small business size standard of $38.5M. Current System for Award Management (SAM) registration is mandatory (www.sam.gov). If your firm is capable of providing these services per the requirements described below, please submit a Capability Statement to: Mr. Kenneth McCright at kenneth.mccright.3@us.af.mil no later than (NLT) 15 May 2015 @ 1600 CST. Please do not call the contracting office for information; email any questions regarding this RFI (NLT 3 May 2015) to avoid any misunderstanding or confusion. The Capability Statement should include general information and technical background describing your firm's experience in contracts requiring similar efforts to meet the program objectives. At a minimum, the following information is requested: (1) Company name, CAGE Code and DUNS number, address, point of contact (POC), POC current telephone number and current email address; (2) approximate annual gross revenue; (3) small business status (8(a), HUBZone, veteran-owned, women-owned, etc.); (4) Indicate if your role in the performance of the requirement would be (a) Prime Contractor; (b) Subcontractor; or (c) Other, please describe; (5) If you indicated your role as "Prime Contractor" on Question 4, indicate the functions for which you plan to use subcontractors; (6) If you indicated your role as "Prime Contractor" on Question 4, please provide brief information you feel would indicate your capability to mobilize, manage, and finance a large service contract such as this; (7) If you indicated your role will be a "Subcontractor" on Question 4, please indicate which functional areas you intend to cover; (8) A brief summary of your company's experience; (9) Indicate whether or not your company would be likely to submit a proposal if a formal solicitation is forthcoming; (10) Indicate which North American Industry Classification System (NAICS) code(s) your company usually performs under for Government contracts; (11) Request large and small businesses provide a reasonable expectation for small business utilization as a percent of a total contract value. Please provide supporting rationale for the recommended percentage. The Government reserves the right to decide whether or not a small business set-aside (SBSA) is appropriate based on responses to this notice. In order for the Government to make an SBSA determination, it is requested that small business concerns provide sufficient written information supporting their capability to perform the requirement listed above. In addition to the information above, please provide responses to the following questions: 1. Can this requirement be provided as firm fixed price (FFP), if so how? 2. Can you describe your proposed method of providing this service? 3. What is your proposed plan for negotiating medical pricing and ensuring bills are paid in a timely manner? 4. How long will it take providers to receive payment on average? 5. What information do you need to coordinate and validate group membership? 6. Do you have the capability to access USG computer systems? 7. Can coverage be provided for all medical treatments requested per the SOO? 8. What would be the rough order of magnitude (ROM) cost to provide coverage per the SOO? 9. Would there be additional cost to have Arabic claim system, if so what is a ROM cost? BACKGROUND/STATEMENT OF OBJECTIVE (SOO): Royal Saudi Air Force Medical Administration Services 1. The USAF has a requirement to provide health care administration services for RSAF personnel and their authorized dependents while assigned in the United States for durations greater than 60 days. The majority of RSAF personnel are trainees, supervisors, or support staff located at USAF, Department of Defense, or commercial training facilities in the continental U.S. (CONUS). The contractor shall support medical administration services for approximately 200 RSAF military personnel and 300 dependents through the duration of the contract. This group is usually distributed across the U.S. with the largest single area of concentration occurring in the Joint Base San Antonio Lackland, TX area. 2. RSAF students are usually assigned to training programs in the U.S. ranging in duration from 6 to 30 months and may change individual training sites several times during this period. The administration of health care services provided by military medical and dental facilities is not included in the scope of the services solicited herein. 3. It is desired to provide a broad selection of high quality health care services to the RSAF personnel and their authorized dependents using a Preferred Provider Organization (PPO). Ideally these services will be available to group members without the necessity that the services be paid for at the time of delivery or that the sponsor be required to file the claim for payment. The claim system will require the health care provider to perform the necessary claim completion and pay the claim in accordance with (IAW) the Covered Services outlined in Attachment A based on the company determining coverage under the benefit plan and the conformance of charges to what's reasonable and customary as defined by a routinely updated, nationally recognized data base of prevailing fees. The company must then promptly pay the providers accordingly. Payment will be authorized on behalf of every covered charge up to the 95th percentile of what is defined as reasonable and customary and is within plan limits. 3.1. The Contractor shall be National Committee for Quality Assurance accredited or accredited by another organization using the Healthcare Effectiveness Data and Information Set and patient experience ratings on a standardized Consumer Assessment of Healthcare Providers and Systems survey, as well as consumer access, utilization management, quality assurance, provider credentialing, complaints and appeals, network adequacy and access, and patient information programs. 3.2 The Contractor shall pay for items not covered by Covered Services outlined in Attachment A or items above the 95th percentile of what is defined as reasonable and customary when approved by the Kingdom of Saudi Arabia (KSA) Air Attaché. KSA Air Attaché approved services shall be charged against a cost plus fixed fee Contract Line Item Number (CLIN). 4. The use of PPO physicians is not mandated. When a RSAF participant chooses to use a physician who is not a PPO member, the group Contractor shall deal directly with the provider for payment, whenever possible. The RSAF will restrict hospital usage to members of a qualified PPO, when available. The PPO should negotiate reduced fees with health care providers for group plans within limited geographic areas. Health care providers reduce their fees in expectation of increased business from the PPO membership. Enrollment of the group in PPOs will be individually by geographic area. 5. In areas where a paperless (to group members) claim system is not possible, it is required that a simplified claim system be developed which, insofar as possible, will permit authorized group members to receive health care services without the requirement to pay at the time of delivery. The claim system shall be in English and Arabic. Whether payment is subsequently due the provider or the group member as a reimbursement, the requirement for Contractor services stated above for screening and prompt payments pertains. 6. Except in emergency situations, RSAF members will be required to secure hospital pre-admission certification and surgical second opinions (when applicable) for hospital in-patient care. The Contractor shall validate medical need, second opinion concurrence, the appropriateness of the planned length of hospital stay, and hospital membership in a PPO or its willingness to negotiate rates as conditions for certifying admission. In cases where admission is denied to a member, the Contractor shall notify the RSAF member, the KSA Air Attaché and the COR of denial of admission and provide a list of alternatives. 7. Individual case management of medical expenses beyond Covered Services will be undertaken on a case-by-case basis when recommended by the Contractor and approved by the CO. Payment for these additional services will be accomplished on a cost reimbursable basis. 8. Group membership includes the RSAF member (sponsor) together with dependents designated by the member and listed in the USAF Sponsored Invitational Travel Order. 8.1 The Contractor shall develop a system to coordinate / validate group membership. The Contractor shall be responsible for maintaining the group membership list in coordination with the designated AFSAT Country Manager. 8.2 The United States Government (USG) reserves the right to allow access to USG databases to support coordinating / validating group membership. The level of access required to USG systems will be defined by the USG. The Contractor shall maintain the ability to access USG "For Official Use Only" (FOUO) Computer Systems. 9. RSAF Health Plan Identification and Prescription Identification Cards. 9.1. During contract mobilization, the Contractor shall provide a draft RSAF Health Plan Identification and Prescription Identification Cards to the Contracting Officer Representative (COR) for acceptance. 9.2. The Contractor shall provide RSAF Health Plan Identification and Prescription Identification Cards to RSAF members already in CONUS at least three weeks prior to the contract effective date. 9.3. The Contractor shall provide RSAF Health Plan Identification and Prescription Identification Cards to RSAF members within one week of arrival CONUS, unless directed by the COR to use overnight delivery. 9.4. All RSAF membership cards will carry the group member's full name (first, middle initial, and last), the sponsor's full name and Work Control Number (WCN), the plan Contractor's full name, toll-free telephone number for verification and hospital precertification (if different), billing address and instructions, an expiration date of the last date of assignment or the last day of the current plan year, whichever date occurs first, and costs and billing/payment disclaimers. Cards will carry a requirement that membership be first-time validated to providers by a photo identification card such as a U.S. Department of Defense (DoD) ID card, passport, or a driver's license. If an authorized dependent does not have a photo ID, the Contractor may use the RSAF member's photo ID. 9.5. Membership cards and plan summaries are required to be reissued on an annual basis at the beginning of each task order. RSAF Health Plan and Prescription Identification Cards will be reissued when a previously reported ITO expiration date is extended for more than thirty (30) days and sixty (60) days respectively. 9.6 RSAF Health Plan Identification cards will be laminated with 10 mil plastic on each side and printed on colored (color determined by the RSAF) paper from a laser printer. 9.7. RSAF personnel assigned for periods of sixty (60) days or less will be designated as sponsors by Extraordinary Inclusion letter from the Air Force Security Assistance Training (AFSAT) Country Manager (CM). The AFSAT CM will provide a copy of the Extraordinary Inclusion letter to the Contractor in order to incorporate the designated RSAF sponsor and dependent(s) under this contract. RSAF Membership and Prescription Identification Cards will not be issued to Extraordinary Inclusion participants. A copy of the Extraordinary Inclusion letter along with a photo identification card by which a sponsor can validate his/her identity will suffice for obtaining medical provider services. In order to obtain prescription drugs, an Extraordinary Inclusion participant will purchase drugs and submit a RSAF Medical Reimbursement Claim Form to the Plan Contractor, who shall reimburse the sponsor by check. Payment for medical, dental, prescription and vision costs will be accomplished on a cost reimbursable basis. 10. The Contractor shall ensure at least 95% of all valid, complete provider billing statements and sponsor claims be screened and paid by the Contractor within fifteen (15) working days of receipt. Health care providers who provided services to group members and have claimed amounts rejected shall be provided a full explanation by the Contractor and advised of appeal procedures. Originals of billing statements shall be maintained by the Contractor for the life of the contract after which time they will be disposed of as determined and directed by the COR. 11. A local area network (LAN) of personal computers with Internet access and electronic mail capability for key personnel is required for communication with the COR. Attachments: Attachment A - Covered Services Attachment B - Reports Attachment C - Service Groups Attachment D - Definitions Attachment A - Covered Services In the services area, the following descriptions for Major Medical, Prescription Drugs, Dental Services, Orthodontic Services, and Eye Care Services, serve as examples of specific and common services for which benefits are provided under the plan. For the purposes of benefit authorization, only those services listed as Exclusions or Limitations are not authorized. The Contractor is requested to verify coverage for questionable services with the COR on an as occurring basis. Age limit for dependent children is 18 years of age unless attending full time college then 23 years of age or a waiver is granted by the COR. A. Major Medical: All medically necessary charges up to those defined as Usual and Customary or Reasonable (UCR) for hospital and medical expenses, professional services, office visits, prescription drugs, medical supplies and other expenses detailed below: (1) Mental health care. All expenses. (2) In-Patient hospital care including: (a) Private room. (b) Operating, recovery, anesthesia, delivery, labor, intensive care, coronary care and cystoscopic rooms. (c) Nursery care for the newborn while mother is hospitalized for maternity care. (d) Meals, including special diets. (e) Drugs and medicines provided by the hospital, including intravenous solutions and injections. (f) Oxygen, and the equipment necessary for its administration, sterile tray service, dressings and plaster casts. (g) Blood plasma and blood expanders. (h) Physical therapy, occupational therapy and inhalation therapy (when furnished by and billed by the hospital). (i) Semi-private accommodations when no private room is available at the time of admission. (3) Outpatient hospital services in connection with accidental injuries, medical emergencies, outpatient surgery and dialysis. (4) Hospital and medical care in connection with an abortion, D&C or full term delivery for female members who are victims of rape and become pregnant as a result of rape. (5) Insulin (including intravenous prescription drugs) and medicines listed in the official U.S. formularies. (6) Artificial limbs or eyes. (7) Casts, splints, trusses, braces and crutches. (8) Rental of a wheel chair or hospital type bed, iron lung or mechanical equipment for the treatment of respiratory paralysis. (9) Local professional ambulance service to a local hospital or beyond the local area to the nearest facility equipped to handle the patient's condition. (10) Professional nursing care by a registered private duty nurse (R.N.) or a licensed practical nurse (L.P.N.). Benefits for private duty nursing skilled care are limited to a maximum of 2 hours per day for up to 50 days in a calendar year where required by patient's condition. (11) Services provided by a certified nurse midwife. (12) Treatment of cleft lip and/or cleft palate disorders. (13) Maternity care including prenatal and postnatal care and complications of pregnancy. (14) Eyeglasses or contact lenses required as a result of surgery, including cataract surgery. (15) The administration of general anesthesia when rendered by a physician, other than the attending physician or his assistant, when given for a covered surgical or obstetrical procedure. (16) Surgery, which includes operations necessary for treatment of a disease, injury or ailment, usual pre-operative and post-operative services, endoscopic procedures (inserting tube to examine internal organs; typical examples - cystoscopy, proctoscopy, sigmoidoscopy), and treatment of fractured and dislocated bones. (17) Benefits will also be paid for well-baby examinations as prescribed by the attending physician. (18) Benefits for diagnostic and laboratory treatment services will be paid wherever performed when they are related to a symptom of a disease or ailment or are part of a routine physical examination. (a) X-ray therapy for the treatment of benign growths or malignant diseases such as cancer (b) Radioisotope service (c) Electrocardiograms (d) Electroencephalograms (e) Tonograms (f) Chemotherapy (19) Allergy test, injections, and serum. (20) Dressing, medical supplies and sterile tray service. (21) Blood transfusions, blood processing, blood handling and the cost of unreplaced blood or blood plasma. (22) Cardiac rehabilitation program benefits for up to 90 visits during a treatment plan rendered by an approved cardiac rehabilitation program provider. (23) Benefits are limited to one annual general physical examination or well-woman examination, including related physician ordered tests. This policy will not limit children who change schools within a year and require new examinations as a condition of entry in the new school. (24) Services in the technical specialties of physical therapy, occupational therapy, chiropractic, licensed speech therapy and pathology, audiology, pain management and podiatry are authorized subject to the following prerequisites. Approval by the Plan Contractor is required on a case-by-case basis prior to the commencement of treatment. (a) Referral for any of these services must be obtained from a medical doctor practicing within an area relevant to the illness or disability for which services are sought. Should services be required beyond a three-month period from their commencement, reevaluation and referral is required. (b) A treatment plan is required from the therapist or chiropractor detailing the frequency and length of therapy, and cost of planned services. Physical therapy and chiropractic services are limited in frequency to twice weekly sessions. (c) The Plan will accept no responsibility for coverage of services not approved by the Plan Contractor prior to the commencement of those services and in each case where continuation of services is required beyond the three-month anniversary. (d) Members or providers who require assistance in interpreting these requirements may contact the Plan Contractor. B. Major Medical Program Exclusions The services identified in this section are not included in the medical plan except under conditions described. Members who accept these services without previous, specific, case-by-case authorization by KSA Air Attaché will be responsible for all associated fees including services, equipment, and associated drugs. (1) Any case provided for, for which benefits may be or could have been obtained in whole or in part, under any Federal or State Compensation Act or similar legislation. (2) Any case to the extent benefits are obtained or could have been obtained upon appropriate application under Medicare. (3) Charges in connection with an illness to the extent the member is entitled to payment from other sources. (4) Charges which would not have been incurred if the member had not been covered by this or similar coverage. (5) Dental services, eye refractions, eyeglasses or hearing aids unless required because of accidental injury while the member is covered. (6) Services related to cosmetic or plastic surgery except for the correction of a condition resulting from an accidental injury, disease or surgery or for congenital anomalies or the correction of a condition for functional reasons. (7) Treatment for weight reduction unless prescribed by a medical doctor. (8) Services and supplies, which are not, FDA approved for the use prescribed. (9) Charges filed later than three years from the date the services were rendered. (10) Charges for reproductive and sexual disorders and defects, whether or not the consequence of disease, illness, or injury except as authorized by the COR on a pre-certified, case-by-case basis. (11) Physician's home office or hospital visits are limited to one visit per day unless warranted by the complexity of the patient's condition. C. Prescription Drugs (1) All charges associated with the provision to group members of out-of-hospital drugs that by Federal law may not be dispensed without a prescription are covered. (a) There is to be no deductible charge for prescription drugs. (b) Covered drugs are those which, by Federal law, are required to bear the legend, "Caution: Federal law prohibits dispensing without prescription." Injectable insulin, which in many states does not require a prescription, is also a covered drug. Prescription orders for oral contraceptives are covered; however, they are limited to a 90-day supply. (2) Exclusions and limitations: (a) Drugs, which do not by Federal law, require a prescription order, except injectable insulin. (b) Drugs requiring a prescription by state, but not Federal law. (c) Supplies of any type, even though such supplies may require a prescription order, including, but not limited to: contraceptive devices, therapeutic devices, artificial appliances, hypodermic needles, syringes (exception in connection with the prescription of injectable insulin), or similar devices. (d) Any charge for the administration or injection of drugs or insulin. (e) The charge for more than a 34-day supply of medication, except that chronic ailment prescription drugs may be dispensed in supplies up to a maximum of 100-dose quantities. (f) The charge for any prescription refill in excess of the number specified by the physician or dentist, or any refill dispensed after one year from the date of the prescription order. (g) Prescription drug charges and Medical Record, PPO Payment and Negotiated Discount Fees and Related Fees approved by the COR will be covered under a cost CLIN. D. Dental Services (1) All charges up to those defined as UCR for the following professional services and associated supplies and expenses: (a) Oral exams (once each six-month period). (b) Bitewings (once each six-month period). (c) Full Mouth Series or Panoramic (in lieu of Full Mouth) Full Mouth or Panoramic x-rays benefits will be provided once every 36 months. (d) Prophylaxis (once each six-month period). (e) Fluoride and sealants (provided once each six-month period in conjunction with routine semiannual prophylaxis for patients under age 16). (2) Palliative emergency services (to alleviate pain). ADA Code 9110 (3) Limitations: The services identified in this section are not included in the dental plan, except under the conditions described. Members who accept these services without previous, case-by-case authorization by KSA Air Attaché will be responsible for all associated fees including services, equipment, and associated drugs. (a) Space maintainers. (b) Diagnostic models. (c) Pulp vitality testing. (d) Consultation service. (e) Restorative services - including amalgam (silver filling), composite and synthetic resin materials, silicate cement, and stainless steel crowns (deciduous teeth only). Fillings or restoration provided only once per calendar year for the same tooth surface. (f) Treatment of acute periodontal disease. (g) Simple repair of dentures and bridges - including repair of removable dentures, repair of broken facings, and recementation of crowns, bridges, facings and inlays. (h) General anesthesia. (i) Oral surgery - limited to routine, simple and complex extractions; alveoplasties; frenulectomies; stomatoplasties; the incision and drainage of abscesses; and the removal of exostosis and hyperplastic tissue. (j) Therapeutic drug injection. (k) Pulpotomy (removal of tooth pulp) and pulp capping in conjunction with the provision of palliative and routine restorative services. (l) Endodontic services - including root canal therapy, apicoectomy (removal of root tip), and retrograde amalgam. (m) Crowns. (n) Crown build-ups to permanent teeth (One crown build up per tooth every five benefit periods). (o) Onlays and inlays (porcelain or gold restorations). (p) Removable prosthetics (full or partial dentures). (q) Other prosthetics. (r) Relining of dentures. (s) Fixed prosthesis (bridges). (t) Periodontal services - including gingival acurettage (removal of growths or material from the gums), surgical modeling of the gingival margin and papillae), and osseous (bone) surgery. (u) Orthognathic surgery. (v) Benefits are limited to one initial oral examination per patient per dentist. (w) Benefits for supplementary bitewings are not provided more frequently than twice in a benefit period (calendar year). (x) Benefits for topical fluoride application are not provided more than twice during a benefit period and will be limited to participants under age 16 only. (y) Benefits are limited to prophylaxis when prophylaxis and gross scaling are rendered on the same dates. (Gross scaling is considered as a component of prophylaxis). E. Orthodontic Services (1) Orthodontics is the branch of dentistry concerned with the diagnosis and treatment of irregularities of the teeth and malocclusion. Orthodontic services are approved for payment only if prescribed by a treatment plan which is a written report prepared by the attending orthodontist showing the recommended treatment of a recognizable malocclusion which is subsequently approved in writing by the Plan Contractor prior to the commencement of billed services. Sponsors considering orthodontic treatment must obtain permission from KSA Air Attaché to undertake the diagnosis phase prior to incurring any expense. Fully supported orthodontic treatment plans must be received by the Contractor no later than 60 days prior to training completion. (2) Orthodontic services available under this Plan if prescribed and approved by a treatment plan include: (a) Diagnosis - This service includes models, photographs, cephalometric radiographs, x-rays and tracings, appropriate to development of the treatment plan. The Contractor will provide verbal approval for this service to be performed in response to the attending orthodontist's request, which must include identification of the member to receive the service and a not-to-exceed cost estimate for the service. (b) Retention - This service follows active treatment and is designed to permanently preserve tooth and bite adjustments achieved. (3) Benefits available as the result of an approved treatment plan for orthodontic services are payable only as long as the sponsor is a member of the medical plan. Additionally: (a) Initial professional services under an approved treatment plan shall be deemed to have been rendered on the date actually performed. (b) Active and retention treatment visits shall be deemed to have been rendered on the first day of each month. (4) Exclusions and Limitations: (a) Benefits for orthodontic services shall be available only to dependents under age 23. (b) The maximum number of months for which benefits are provided for active or retention treatment may be reduced by the number of months has been such treatment received before the commencement of sponsor's plan eligibility. (c) If orthodontic services are terminated before completion, plan liability ceases with payment through the month of termination. (d) There will be no plan liability for the replacement and/or repair of any appliance, which was initially furnished under an approved orthodontic service treatment plan. F. Eye Care Services (1) The eye care program provides payments for regular professional eye care services including periodic eye examination and necessary corrective eyewear supplied by an Ophthalmologist or other Doctor of Medicine, an Optometrist or an Optician acting within the scope of his license. (2) The program will compensate an eye care provider for eye services rendered, in an amount equal to the lesser of the allowance specified in the schedule of allowances set forth below or his regular charge (which shall be that fee regularly charged for a given eye care provider to all of his patients). Benefits include the following services or supplies: (a) Services: 1. $100.00 - Eye Examination - An Eye Examination determines visual defects and ocular refractive deformities and deficiencies of the human eye, including refraction and prescription. A medical doctor or optometrist may perform such an examination. 2. $120.00 - Comprehensive Medical Eye Examination - A Comprehensive Medical Eye Examination is an eye examination as defined above, and in addition is designed to diagnose diseases and abnormalities of the body, which can be determined through examination of the eye. Only a medical doctor may perform such an examination. 3. During each 24-month period a member is entitled to: a. One Eye Examination or one Comprehensive Medical Eye Examination for group members under the age of 50. Yearly examinations permitted for members over the age of 50. b. One pair of lenses and set of frames or one pair of contact lenses. (i) Supplies: 1. $130.00 - Single Vision Lens and frames 2. $200.00 - Bifocal Lens and frames 3. $250.00 - Trifocal Lens and frames (3) Exclusions (a) Medical or surgical treatment of the eyes (these services are covered under the major medical portion of the plan). (b) Any examinations, materials or services, which are not listed herein as a covered service or supply. (c) Duplicate or spare eyeglasses, or any lenses or frames for duplicate or spare eyeglasses or to replace those, which have been lost, stolen or broken. (d) Any lenses which do not require a prescription. (e) Safety glasses or safety goggles. (f) Visual field examinations. (g) Drugs or any other medication (except those used during the examination of the eye and which should be included in the examination charge). (h) Eye exercises including remedial reading exercises Attachment B - Reports A. Monthly Program Reports (1) The contractor will provide the below listed monthly program summary reports (as of the close of business on the last calendar day of the month) to the COR to be received not later than the 10th calendar day of the following month. RSAF approval of report formats is required prior to issuance of the initial reports after contract implementation. (a) Paid Claims Report 1. Transactions by FMS case in sequence by payment date, listing: a. Date of payment b. Sponsor Work Control Number (WCN) c. Patient Last Name, First, M.I. d. Relationship to sponsor (S, W, C, D) e. Date(s) of service f. Provider g. Amount billed h. Check number i. Amount paid (b) Eligibility Report 1. List of authorized participants by FMS Case a. Patient Last Name, First, M.I. b. WCN c. Date of Birth (DOB) d. Age e. Sex f. Effective Date g. Termination Date (c) Turnaround Time Report 1. Claims received by day 2. Claims processed by day 3. Percent of claims processed by day 4. Cumulative percent of claims processed by day B. Quarterly Program Reports (1) The provider will produce a quarterly report to the COR that outlines the medical service fees that have been negotiated on the part of the customer. The report will display consolidated medical charges that were evaluated for fair reimbursement by comparing charges to industry standards and subsequently negotiated by the provider to reflect a fair and reasonable fee. Report shall be submitted no later than 15th calendar day of the following quarter. COR approval of report formats is required prior to issuance of the initial reports after contract implementation. Attachment C - Service Groups M0 - Equipment Rental/Purchase Sl - Radiography & Laboratory Ml - Hospital Inpatient S2 - Chiropractic M2 - Surgeon Inpatient Pl - Prescriptions M3 - Doctor(s) Inpatient Dl - Dental M4 - RAD & AMES Inpatient D2 - Orthodontics M5 - Emergency Room V1 - Vision Care/Services M6 - Surgery Outpatient V2 - Vision Care/Supplies M7 - Doctor Outpatient M8 - Medical Record, PPO Payment and Negotiated Discount Fees, and Related Fees as approved by the COR M9 - Total Psychiatric M10 - Non-Medical   Attachment D - Definitions Preferred Provider Organization (PPO): A type of health plan where you pay less if you use providers in the plan's network. You can use doctors, hospitals, and providers outside of the network without a referral for an additional cost.
 

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