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HomeMy WebLinkAboutNATIONAL HEALTH SYSTEMS - CONTRACT - RFP - P682 BENEFITSSERVICES AGREEMENT THIS AGREEMENT made and entered into the day and year set forth below by and between THE CITY OF FORT COLLINS COLORADO a Municipal Corporation hereinafter referred to as the City and NATIONAL HEALTH SYSTEMS INC hereinafter referred to as "Service Provider" WITNESSETH In consideration of the mutual covenants and obligations herein expressed it is agreed by and between the parties hereto as follows 1 Scope of Services The Service Provider agrees to provide services in accordance with the scope of services attached hereto as Exhibit 'A consisting of four (4) pages and incorporated herein by this reference 2 Contract Period This Agreement shall commence January 1 1999 and shall continue in full force and effect until December 31 1999 unless sooner terminated as herein provided In addition at the option of the City the Agreement may be extended for additional one year periods not to exceed four (4) additional one year periods Pricing Is set forth in Exhibit C consisting of two (2) pages and incorporated herein by this reference Service Provider will guarantee fees for the first year of the contract and agree to a maximum fee increase of 5% for year two a maximum fee increase of 7% for year three a maximum fee increase of 7% for year four and a maximum fee increase of 7% for year five Written notice of renewal shall be provided to the Service Provider and mailed no later than ninety (90) days prior to contract end 3 Delay If either party is prevented in whole or in part from performing its obligations by unforeseeable causes beyond its reasonable control and without its fault or negligence, then the party so prevented shall be excused from whatever performance is prevented by such cause To SA 10/97 1 Statement of Reasons for Specification Deviations TPA SERVICES - SPECIFIC INFORMATION Item 5 NHSI provides an Explanation of Benefits Form to the participant with respect to denial of benefits Items 7, 8, 9, 10 NHSI provides the reports as noted in Attachment C to this proposal Item 12 NHSI will prepare and distribute on an annual basis the 1099 forms which are required by federal law Other forms required by state or federal law may incur additional expense to the City Item 14 NHSI will guarantee a turn -around time of 95% of ail "clean" claims of not more than ten (10) working days which includes the period from the date the claim is received and date stamped in our office to the date the claim is adjudicated or fourteen (14) working days to the day the check is issued We altered this requirement because we issue checks one day a week Item 17 NHSI will provide the check stock if the existing corporate claims account is used We will provide claims forms and other materials necessary to administer the medical plan We do not produce or provide identification cards M EXHIBIT `B' YEAR 2000 COMPLIANCE CERTIFICATION AND INDEMNITY Section 1 Contractor hereby cemfies that all information resources or systems to be provided or used in connection with the performance of this Agreement are "Year 2000 Compliant", except as otherwise expressly described in Section 2 below 'Year 2000 Compliant" shall mean that information resources meet the following criteria a Data structures (e g , databases, data files) provide 4-digit date century recognition For example "1996" provides date century recognition "96" does not b Stored data contains date century recognition, including (but not limited to) data stored in databases and hardwareldevice internal system dates c Calculations and programs logic accommodate both same century and multi -century formulas and date values Calculations and logic include (but are not limited to) sort algorithms calendar generation, event recognition, and all processing actions that use or produce date values d Interfaces (to and from other systems or organizations) prevent non -compliant dates and data from entering any state system e User interfaces (i e , screens, reports etc ) accurately show 4 digit years f Year 2000 is correctly treated as a leap year within all calculation and calendar logic Section 2 Contractor has identified the following information resources or systems that will be provided or used In connection with the performance of this Agreement that are not, or will not by December 1, 1998, be Year 2000 Compliant The system we are propOsIng is not Year 2000 CcmAliant However, M SI is Currently unplementing a new claims system that is Year 2000 Carmliant A11 Information resources and asterm used in connection with the znerfor marice of this Acrreement will be -Year 2000 COPI ant by the year 2000 1 Section 3 a Contractor hereby certifies that the instances of information resources or systems not Year 2000 Compliant identified in Section 2 above will be Year 2000 Compliant no later than December 1 1998, and that Contractor shall notify the City of the status of Year 2000 Compliance for such resources or systems upon the earlier of the date Year 2000 Compliance is achieved or on June 30 1999 b Contractor hereby certifies that the instances of information resources or systems identified in Section 2 above as not Year 2000 Compliant and for which Year 2000 Compliance is or will not be achieved by December 1 1998 are not related to and do not impair the performance by Contractor of the terms of this Agreement, and do not produce new non -compliant information resources or systems Section 4 Contractor agrees to notify the City immediately of any information resources or systems that are not Year 2000 Compliant upon encountering the same in connection with the performance of the Agreement including without limitation any information resources or systems in use by Contractor in the performance of the Agreement or information resources or systems of the City regarding which Contractor obtains information in the course of its performance of the Agreement Section 5 Contractor agrees to permit examination by the City or agents thereof of any and all information resources and systems in use in connection with this Agreement and related Year 2000 Compliance implementation plans in order to evaluate Year 2000 Compliance and potential implications of the same for the City and for performance of the Agreement Section 6 The Contractor shall indemnify and hold harmless the City and its officers, agents and employees from and against all claims, damages losses and expenses including attorneys fees, arising out of or resulting from the Contractor's failure to disclose instances of information resources or systems that are not Year 2000 Compliant or failure to comply with the terms of this Exhibit B 7/98 EXHIBIT C TPA SERVICES FEE QUOTATIONS Please provide your fee quotation with regard to the administrative services described in this section Your fee quotation should be presented in the following format PPO PIS Without t Run -In Medical Claims Admrmstratron Additional Charges COBRA Adrnuustration Retiree Administration H1PAA Administration ID Cards Start -Up Fees Other (detail) COBRA me Charges I Per $ 9 10/EE/Month* $ 10 00 per electron/notice $ 13 65/EE/Month $ 10 00 Her certificate $ We don't provide For purposes of your quote, please assume 605 eligibles in the PPO plans Charges IEPO Plans Onl77 y Per Ehgibla Run -In SOS E� Claims Administration $ $ RAdministration $ $ r9911Wy al ChargesA $ Adrrunistratron $ Per per election/notice electlon/notrce e Admuustration Administrationrds $ $ p Fees $ $ (detail) $ $ For purposes of your quote please assume 80 eligibles in the POS plan and 585 in the EPO plan *This fee includes docrunented expenses of $1 60 per eligible per month (averaged over the past 18 rnonthsThese ef pense Jude Hostage long distance telephone, pruzg oclaim inc forms, and EOBs 1 THIS FORM MUST BE COMPLETED BY ALL PROPOSERS CITY OF FORT COLLINS, COLORADO PROPOSAL FORM Our proposal is valid for 90 days 2 Fee/Rate Guarantee PPO Network months POS Network months EPO Network months TPA 60 months UR months Stop -Loss months Carve -Out PPO Prescription Drugs months 3 Standard & Poor's Rating (if applicable) N/A 4 Commissions Yes No X If yes To whom $ /year 5 Contact Name (in case of questions regarding proposal) Mr Lorne Gale Telephone Number (303)799-6882/(800)253-0636 Fax Number (303) 799-6894 6 Carrier Name N/A 7 Complete the following National Health Systems, Inc 153 Inverness Drive West, Suite 300 COMPANY NAME ADDRESS D July 29, 1998 9 Colorado 80112 DATE CITY STATE, ZIP CODE Arapahoe SIGNATURE COUNTY Philip G Reisbeck (303)799-6882/(800)253-0636 PRINTED SIGNATURE TELEPHONE President TITLE FAX NUMBER ANSWERS MUST BE PROVIDED FOR ALL ABOVE QUESTIONS ON THIS FORM DO NOT REFERENCE ANOTHER SECTION OF THE PROPOSAL FOR YOUR RESPONSE 2 EXHIBIT D INSURANCE REQUIREMENTS ble to the The Service Provider will d pay all frominsurance Before commenting workunder tth s bid, City, the Service Providershall coverage designated hereinafter and pay furnish the City with certificates of insurance showing the type, amount Bass of operations covered effective dates and date of expiration of policies and containing substantially the following statement" " "The insurance evidenced by this Certificate will not be canceled or materially altered except after ten (10) days written notice has been received by the City of Fort Collins ' In case of the breach of any provision of the Insurance Requirements the City at its option may take out and maintain at the expense of the Service Provider such insurance as the City may deem proper and may deduct the cost of such insurance from any monies which may be due or become due the Service Provider under this Agreement The City its officers agents and employees shall be named as additional insureds on the Service Provider's general liability and automobile liability insurance policies for any claims ansing out of work performed under this Agreement 7198 EXHIBIT E CONFIDENTIALITY AGREEMENT IN CONNECTION WITH SERVICES provided to the City of Fort Collins (the City ) pursuant to this Agreement (the 'Agreement') the Contractor hereby acknowledges that it has been informed that the City has established policies and procedures with regard to the handling of confidential information and other sensitive materials In consideration of access to certain information data and material (hereinafter individually and collectively regardless of nature referred to as information") that are the property of and/or relate to the City or its customers or suppliers which access is related to the performance of services that the Contractor has agreed to perform the Contractor hereby acknowledges and agrees as follows That information that has or will come into its possession or knowledge in connection with the performance of services for the City may be confidential and/or proprietary The Contractor agrees to treat as confidential (a) all information that is owned by the City or that relates to the business of the City or that is used by the City in carrying on business and (b) all information that is proprietary to a third party (including but not limited to customers and suppliers of the City) The Contractor shall not disclose any such information to any person not having a legitimate need -to -know for purposes authorized by the City Further the Contractor shall not use such information to obtain any economic or other benefit for itself or any third party except as specifically authorized by the City The foregoing to the contrary notwithstanding the Contractor understands that it shall have no obligation under this Agreement with respect to information and material that (a) becomes generally known to the public by publication or some means other than a breach of duty of this Agreement or (b) is required by law regulation or ourt order to be disclosed provided that the request for such disclosure is proper and the disclosure does not exceed that which is required In the event of any disclosure under (b) above the Contractor shall furnish a copy of this Agreement to anyone to whom it is required to make such disclosure and shall promptly advise the City in writing of each such disclosure 7/98 ATTACHMENT A QUESTIONS TO BE ANWERED BY ALL PROPOSERS GENERAL QUESTIONS TO BE ANSWERED BY ALL PROPOSERS All proposals submitted must include answers to the following questions Administrative Agreements and General Information 1 It is the intention of the City that the master contract reflect the elimination of the actively - at -work restriction or deferred effective date for all initially enrolled active or inactive employees and dependents This will include only initial eligibles (those eligible on the effective date of the contract) including COBRA continuees Please indicate your agreement with this requirement Yes, we agree with this requirement 2 It is required that proposals assume that all participants (including COBRA) presently covered will be covered under a successor plan regardless of medical condition, disabled status, or whether they are actively -at -work or on a no -loss no -gam basis for both the City and the participant If your proposal written in accordance with this requirement? Yes our proposal is written in accordance with this requirement 3 If your company is awarded this business, how soon after notification of the award would you be able to have a draft of the contract? Immediately 4 If the services furnished by your company differ in any respect from those described, please indicate where such differences exist If you do not indicate any differences, it will be assumed that the services included in your proposal do, in fact, exactly match those described All differences have been noted in the proposal 5 Provide a sample contract similar to the one that would be used for the City City Standard Services Agreement is enclosed as Exhibit A , note specific exception or changes requested A copy of our current Agreement is enclosed with this proposal as Attachment A 'r' 6 Commissions or fees of any type are not to be paid to any entity as part of the cost of the services requested in this specifications letter Is your proposal written in accordance with this provision? Yes, our proposal is written in accordance with this provision 7 Please provide at least three Colorado (preferably municipality plans with at least 500 employees) references (not current Segal Company clients) for each service you are proposing List the name of the organization, address, telephone number, and contact person s name and title If your company is quoting all or a portion of the benefits included in this Request for Proposal, please provide references for each benefit you are proposing Also, provide the name and telephone numbers of any clients you are not now serving that you were serving three years ago Why are you not providing service to these clients? Poudre R-1 School District 2407 LaPorte Avenue Fort Collins CO 80521 Denver Public Schools 900 Grant Street Denver CO 80203 Exempla HealthCare 1835 Franklin Street Denver CO 80218 Ms Julia Taylor Benefits Manager (970)482-7420 Mr Robert Mtllsap Director of Employee Benefits (303)764-3769 Ms Dons Cowan Benefits Manager (303)837-7987 We have never lost a client for service reasons Most have gone from a self -insured plan to fully -insured or have merged with other companies We have only lost one client in the past three years National Jewish Center 1400 Jackson Street Denver CO 80206 Human Resources Dept (303)398-1037 8 Provide samples of any communication materials that would be provided by your company to the City at no additional cost What customized materials are available? Please identify the retention costs associated with these communication materials N/A, our proposal is for Claims Administration only 3 the extent that the performance is actually prevented the Service Provider must provide written notice to the City of such condition within fifteen (15) days from the onset of such condition 4 Early Termination/Notice Notwithstanding the time periods contained herein the City or Service Provider may terminate this Agreement at any time without cause by providing written notice of termination Such notice shall be delivered at least sixty (60) days prior to the termination date contained in said notice unless otherwise agreed in writing by the parties All notices provided under this Agreement shall be effective when mailed postage prepaid and sent to the following addresses City Human Resources City of Fort Collins P O Box 580 Fort Collins CO 80522 Service Provider Phillip G Reisbeck President National Health Systems Inc 155 Inverness Drive West Suite 300 Englewood CO 80112 In the event of early termination by the City the Service Provider shall be paid for services rendered to the date of termination subject only to the satisfactory performance of the Service Provider's obligations under this Agreement Such payment shall be the Service Providers sole right and remedy for such termination 5 Contract Sum The City shall pay the Service provider for the performance of this Contract as set forth in Exhibit C consisting of two (2) pages and incorporated herein by this reference 6 City Representative The City will designate prior to commencement of the work its representative who shall make within the scope of his or her authority all necessary and proper decisions with reference to the services provided under this agreement All requests concerning this agreement shall be directed to the City Representative SA 10/97 2 9 Would you agree to contractual performance guarantees regarding telephone calls, referrals, access standards, i d card, NCQA accreditation? Please provide the specific standards and examples of similar arrangements with other clients We currently have a performance agreement with the City (please see attachment A) 10 The City will require that contracts include language that any data associated with the City's plan is the property of the City and, as such, must be available to the City (e g , when changing vendors) Please indicate your acceptance of this requirement Yes, we agree with this requirement 11 Recordkeepmg a Discuss how employee and dependent records are maintained This data can maintained in two different ways 1 This first way is the method our larger clients use An existing PC is made compatible with our system by adding a "board" to the PC Then the PC is hooked to a modem to allow direct access to our computer A subset of transactions is made available to the client to maintain these files Note The City currently utilizes this method 2 The other way would be to have the client send the data on hardcopy to maintain these records to our office where our personnel would make the changes in the system b Indicate your data needs from the City in order to administer this program N/A, as we currently administer the City's program c How will your organization verify eligibility? Eligibility is verified automatically with the computer If there is a question about eligibility, we have manual intervention to resolve the question 12 Confirm that you will be Year 2000 compliant and describe your procedures to become compliant NHSI has a new claims system that is Year 2000 compliant, and will be in use well before the year 2000 i 13 How does your organization handle the surcharge requirements of New York and Massachusetts? What impact do these surcharges have on your clients (e g describe charges, if applicable)? We handle all procedures to facilitate this requirement We currently charge on a time and materials basis As we get more expenence doing this function, we may be able to charge a fixed fee per month for this service Fee and Rate Guarantees 1 These specifications require that any fees quoted in your proposal be firm and guaranteed for a minimum of 12 months and cannot be changed by recalculation based on actual enrollment Please indicate your agreement to this requirement Is your organization willing to provide a multiple year guarantee or a second year cap on fees? Please specify separately for each service NHSI will guarantee our fees for the first year of the contract and agree to a maximum fee Increase of 5% for year two, a maximum fee Increase of 7% for year three, a maximum fee increase of 7% for year four, and a maximum fee Increase of 7% for year five 2 The City is requesting that formal renewal notice for all coverages be received no later than four months or 120 days prior to the renewal date of the program Please indicate your agreement to this stipulation NHSI does agree to this stipulation 3 When are fees due and what is the grace period for payment of fees under your agreements If premium is paid subsequently, is a penalty and/or interest charges assessed if yes, please explain in detail Fees for our administrative services are due to our office within 10 days of receipt of our Invoice The Interest rate would be Norwest Bank's `pnme rate" in effect at the time of the assessment on the outstanding balance for each month there is a delinquency 4 Are there any options available with respect to the grace period? If so, please explain the option(s) and any charge that is made for them No there are not any options available 5 5 The contracts are to provide that change in fees can only be instituted on January 1 Please indicate whether your company is willing to issue master contracts reflecting this provision N/A, our proposal is for Claims Administration only The master contract Is typically issued by the Benefit Consultant Our Administrative Services contract would reflect this provision 6 Can the individual services proposed by your company be purchased separately or are they interdependent upon each other? Please be specific and elaborate on any fee consideration N/A, our proposal is for Third Party Administrative Services only Organization Issues 1 Please describe your organization addressing the following items a Ownership b Length of time in business c Affiliated organizations, and d include a copy of your most recent audited financial statement National Health Systems, Inc has been owned by Philip G Reisbeck and Linda G Reisbeck since its inception in 1977 NHSI is not affiliated with any organizations A copy of our most recent audited financial statement is included with this Proposal as Attachment B 2 Provide a statement signed by an Officer of your company that your firm has adequate personnel and financial resources to provide the services indicated in this Request for Proposal NHSI has adequate personnel and financial resources to provide the services indicated in this Request for Proposal G R'eisbeck, President 3 If applicable, indicate the location of the claims office where claims would be processed and/or member services is handled Is a toll -free phone number available for member inquires? What are the hours? If a toll -free phone number is not available, will you establish one at no additional charge? Include a description of your member services O NHSI's claims/member services office Is located at 155 Inverness Dnve West, Suite 300 Englewood, Colorado 80112 Our telephone number Is (303)799-6882 NHSI does provide 1-800 toll free telephone service for the benefit of the employees and their dependents There is no additional charge for this service The telephone number is 1(800)253-0636 NHSI's normal business hours are from 730 a m to 4 30 p m We are available for employee questions/review purposes from 8 00 a m -12 noon and 100 p m to400pm NHSI feels that client service is of the utmost importance in claims administration Therefore, claims processors are the direct link between our company and the insured participants The processors are best able to answer questions quickly and accurately It is imperative that they are ready, willing and able to help participants through the insurance process Processors also serve as liaisons between company representatives and the insureds Should a difficult situation anse, a supervisor is always available to help resolve the matter in question 4 Is your firm licensed in the state of Colorado (if applicable)? Please confirm that your proposal and/or plan design offered is in compliance with all federal and state laws and regulations that pertain to employee benefit programs relevant state insurance regulations and other related laws Colorado does not require licensing for Third Party Administrators We are proposing to do TPA services only We are not proposing a plan design and therefore the rest of the question is not applicable 5 Please identify the individual responsible for the account in the event of claim disputes, service problems etc Claims disputes, service problems, etc, will be handled by our Claims Supervisor, Ms Mary Schlobohm 6 In the event the City desires employee meetings to present your proposed plan, are representatives from your company available to make presentations? If "yes", are there any additional costs associated with these services? We are proposing TPA services only and not a 'plan" therefore this question is not applicable 7 Do you agree that if this proposal results in your company being awarded a contract and if in the preparation of that contract, there are inconsistencies between and what was proposed and accepted versus the contract language that has been generated and 7 executed that any controversy ansing over such discrepancy will be resolved in favor of the language contained in the proposal or correspondence relating to your proposal? Yes, we agree 8 Are there any outstanding legal actions pending against your organization? If so, please explain the nature and current status of the action(s) There are no legal actions pending against NHSI 9 Please state the time line your company intends to follow to commence work as of January 1, 1999 We are the current Administrator and all services would continue uninterrupted 10 What is your perspective on the health care industry in five years? What changes do you foresee? We foresee more control and mandates from government The healthcare industry has been reforming Itself since the Clinton escapade Soon the industry will be controlled by the very large players (HMOs, etc) and small players will be forced into different arenas 11 If you have obtained national accreditation, please state through which agency and when it was obtained No, we do not have national accreditation [3 ATTACHMENT C THIRD PARTY ADMINISTRATION (TPA) SERVICES TPA SERVICES QUESTIONS TO BE ANSWERED Claims Administration 1 From what city will claims be administered? NHSPs claim office is located at 155 Inverness Drive West, Suite 300 Englewood, Colorado 80112 2 What are your normal business hours? NHSPs normal business hours are from 7 30 a m to 4 30 p m We are available for employee questions/review purposes from 8 00 a in -12 noon and 100 p in -4 00 p in 3 How long have you administered managed care plans? Define dates as applicable, for each network plan NHSI has performed health care claims administration for the past sixteen years 4 Do you provide in -state and/or national WATS telephone service? What is any are the additional charges for this service? NHSI does provide 1-800 toll free telephone service for the benefit of the employees and their dependents There is no additional charge for this service 5 Describe your company's performance standards with respect to a employee inquiries (both written and telephonic) Employee inquiries whether written or telephonic, are handled on a priority basis Because multiple processors are trained on each account, most telephone calls are answered by a processor immediately In the event that it is necessary for someone to leave a message, we require the processor to return the call promptly Written inquiries are responded to as soon as the processor is able to research the matter in question A supervisor responds to any written inquiry that is not routine and is also available to assist with telephone calls 10 b claims turnaround 90% of clean claims in 14 calendar days c claims accuracy 99% financial accuracy Please indicate your actual performance during the 1997 calendar year in attaining these standards Our accuracy averaged over 99% for all groups for 1997 6 Is your firm willing to incorporate guaranteed turnaround time, COB recovery and quality performance standards in its contract with the City? Please detail under what conditions and terms your company would be willing to negotiate Yes, NHSI is willing to incorporate guaranteed turnaround time and certain quality performance standards in the contract We can not guarantee COB recovery as it is directly related to the number of working spouses and/or retirees We do an excellent job recovering COB dollars and identifying subrogation and other third party liability The performance standards would need to be discussed with the City 7 Describe your company's quality assurance and/or internal audit procedures and programs Are you willing to provide the client with quarterly audit reports on its claims? Are you willing to allow an annual audit be performed by an external auditor? All claims processed by new employees are audited As the processor becomes more proficient, a dollar limit between $100 00 and $5,000 00 is set Limits are increased gradually up to the $5,000 00 maximum In addition, all questionable claims are reviewed regardless of the dollar amount We will randomly select a specified number of claims each quarter for audit Quarterly audit reports will be available to the client NHSI does provide for an annual audit to be performed by an external auditor 8 Describe your organization s error and omissions insurance NHSI has a $1 000,000 error and omissions policy underwritten by Legion Indemnity Company 9 Describe in detail your claims adjudication hardware and software systems, and in particular, your claims editing capabilities Specifically, address how it checks for procedural discrepancies based on diagnosis diagnostic 'creep", duplication of claims and procedural unbundling What percent of claims are detected by these edits? What 11 10 percent of dollars claims? How do you treat claim detected as a result of these edits? Is this software/hardware capable of producing special reports, tapes, data transfers that may be requested by the City If so, is there an additional expense for these requests? List costs NHSI is self-contained with respect to data processing We have on site a large computer facility The computer equipment includes a UNISYS A18 main frame containing ninety- six million bytes of memory Currently, we have twenty billion bytes of on line disk storage and no limitation to the expansion All other peripheral devices and equipment necessary to do on line, real time processing are on site All software was developed in-house It is the responsibility of each processor to screen claims for procedural discrepancies based on diagnosis, diagnostic "creep" and procedural unbundling Duplicate claims are detected by the system All questionable claims are referred to our medical reviewer for a determination of benefits We do not maintain a record of the claims detected by these edits Our software/hardware is capable of producing special reports, etc Cost would depend on the request We do not have software that will identify procedure unbundling or procedure "creep" When a claim is submitted for payment, please check below how the following procedures are addressed Claim Inventory X Eligibility of employee X Eligibility of dependent X Usual, customary, reasonable X Benefit plan excluded charges X Pre-existing conditions X Adjudication X Coordination of benefits X Check issuance X Subrogation X Explanation of benefits issuance X UR authorized inpatient days X Medical necessity X Deductible X X Out-of-pocket benefit maximums X Coinsurance X Duplicate charges X X Second option program X Copays X Preferred provider/ X non preferred provider X Unbundling of charges X Workers compensation X 12 11 How do you propose to collect claims data from the prior third party administrator to accommodate a smooth transition? N/A as we are the current Administrator 12 Present an implementation plan to begin adjudicating claims January 1, 1999 assuming a September 1, 1998 notification N/A as we are the current Administrator 13 In the event of termination, what is your guaranteed fee to provide for payment of run -out claims'? Include all data processing charges Our run -out fee would be $8 501claim processed If the current file format for data Is acceptable, there would be no charge If the client wants their data in a different format, we would charge an hourly fee for programming 14 What mechanisms are in place for claims administration backup? Are you proposing a dedicated claims administration unit and 800 number for the City? NHSI has adequate staff to accommodate claims administration backup We currently have multiple processors who are familiar with the City Plan An 800 toll -free number will be available for the City 15 Are you able to administer on-line, electronic transfer, and tape -to -tape eligibility transfers? How does this impact your cost proposal? On-line - Yes Electronic transfer- Yes Tape -to -tape transfers - Yes This does not effect our cost proposal 16 Do you have the capability for the City to have access to your claims and eligibility system through an on-line system? What, if any, are the additional costs? We do have the capability for the City to have access to their claims through an on-line system and they are currently set up to do so We are not charging the City for this service 13 7 Independent Service provider The services to be performed by Service Provider are those of an independent service provider and not of an employee of the City of Fort Collins The City shall not be responsible for withholding any portion of Service Provider's compensation hereunder for the payment of FICA Workmen s Compensation or other taxes or benefits or for any other purpose 8 Personal Services It is understood that the City enters into the Agreement based on the special abilities of the Service Provider and that this Agreement shall be considered as an agreement for personal services Accordingly the Service Provider shall neither assign any responsibilities nor delegate any duties arising under the Agreement without the prior written consent of the City 9 Acceptance Not Waiver The City s approval or acceptance of or payment for any of the services shall not be construed to operate as a waiver of any rights or benefits provided to the City under this Agreement or cause of action arising out of performance of this Agreement 10 Warranjy Service Provider warrants that all work performed hereunder shall be performed with the highest degree of competence and care in accordance with accepted standards for work of a similar nature 11 Default Each and every term and condition hereof shall be deemed to be a material element of this Agreement In the event either party should fad or refuse to perform according to the terms of this agreement such party may be declared in default thereof 12 Remedies In the event a party has been declared in default such defaulting party shall be allowed a period often (10) days within which to cure said default In the event the default remains uncorrected the party declaring default may elect to (a) terminate the Agreement and seek damages, (b) treat the Agreement as continuing and require specific performance, or (c) avail SA 10/97 3 17 Does your system handle member files as opposed to subscriber files? Provide samples of "per member' utilization reports which reflect this capability Yes, our system does handle member files as opposed to subscriber files Samples are provided in Attachment C to this proposal 18 Do you have physicians and patient profiling/reporting capabilities? If so, please describe the standard reports available and ad hoc capability Provide sample reports No, we do not have these capabilities 19 How would your organization determine usual, customary and reasonable charges for medical, surgical and anesthesia procedures? Answer this question in specific detail for PPO, POS and EPA claims, and by area (Colorado, national, worldwide) How often is this data updated? NHSI utilizes the current edition of the St Anthony Publishing Relative Value for Physicians (RVP) with specific conversion factors determined by the client and their consultant We have computer reports that will assist in the determination and updating of conversion factors The unit value associated with a particular CPT code is multiplied by the appropriate conversion factor to determine UCR Each individual PPO has its' own unique conversion factors For out -of -area claims we use the Physician Fee Reference Comprehensive Fee Report We would extract the 90th percentile allowed amount for the particular procedure code Then to calculate UCR, we would multiply this allowed amount by the geographical multiplier On the rare occasion that we receive a claim for services rendered outside the United States, our current clients have requested that the charges In question be paid as billed UCR data is updated by the client's consultant 20 Would you be willing to provide underwriting review for medical evidence for enrollments other than during open enrollment periods? Would there be an extra charge for this service? if so please state your charges Yes, we would be willing to provide underwriting review for medical evidence for late enrollments other than dunng the open enrollment penods There would be no additional charge for this service assuming the number of late applicants would be reasonable 21 If claims exceed the individual attachment point, how often are updated claim reports sent to the stop -loss carrier? Explain this process of coordination with the stop loss carrier Updated claim reports are sent to the stop -loss Gamer monthly 14 Once a claim has exceeded the individual attachment point, a request for reimbursement is filed with the stop loss cameras soon as all relevant information (i e , canceled checks, EOBs, etc) is available Requirements may vary from stop loss camer to stop loss camer However, most careers require that the following documentation be submitted with the request for reimbursement a A copy of the Employee's original enrollment card (including any changes) b A fully completed claim form c Copies of all medical bills and corresponding Explanation of Benefit statements d Front and back of all checks over a specified dollar amount 22 Please submit a sample of your proposed claim and Explanation of Benefits forms Would you be willing to customize the information contained in these forms? Would there be an additional cost? A sample of our Explanation of Benefits form is attached to this proposal on page 28 of Attachment C We would prefer you use the HCFA 1500 claim form with your name and address on the form The Explanation of Benefits form cannot be customized as the forms are generated by the computer system and used for several clients 23 Please state what records (including the participant and data processing documents) would in fact belong to the City upon contract termination NHSI considers all reports related to administrative activities to be the property of the client These records would be delivered to the City, or their designee, upon termination of the Agreement 24 In the event of contract termination when would records which are property of the Plan be released to the parry or organization designated by the City? Describe your termination notice requirement The records would be transferred to any designated party lust as quickly as it is possible to accommodate the request This includes magnetically encoded data pertaining to administrative services provided to the client Upon termination of the contract it would be the responsibility of NHSI to provide to the client adequate information to insure proper understanding of all files and data processing records NHSI requires a 60-day termination notice 25 What non-standard claim utilization and payment reports are available? What, if any are the additional costs? 15 Copies of all available reports are enclosed with this proposal as Attachment C and are included in our administrative service fee The standard reports are produced on a weekly, monthly, and quarterly basis The non-standard reports are produced on an as requested basis 26 It is required that all reporting requirements be included in your per capita administrative fee Would you agree with this provision? Yes, we would agree with this provision 27 Will a representative attend and assist in open enrollment meetings? Is a representative available to meet with employees other than during open enrollment? Is there a separate charge for this service? A representative could be available for open enrollment meetings if It was mutually agreed that this could be cost justified A representative is available during normal business hours Depending on the time involved, there may be a charge to attend open enrollment meetings 28 Provide details of your company's claims dispute resolution procedures National Health Systems employs medical consultants when we need claims reviewed We use the Colorado Foundation for Medical Care, various PPO review boards, and other consultants as needed Formal appeals are rarely filed with the health plans that are administered by NHSI Our philosophy is that complaints and difficult issues should be handled, whenever possible, before the insured feels the need to file a formal appeal Since there are many insurance issues that are not clearly defined, NHSI works together with the appropriate consulting firm as well as employee benefit representative to resolve problems We follow ERISA guidelines for claims appeals A description of the ERISA guidelines should be in your Summary Plan Description as provided by your benefit consultant 29 Do you agree to furnish monthly and year-to-date average enrollment, and total claims paid by line of coverage showing the information separately for active, COBRA , and retirees, and separately for employees and dependents? Yes, we agree to furnish the above mentioned data 30 Please describe in detail what claim reports would be provided at no cost to the City and consultant Please describe the utilization data to be included in your reports For example, number of hospital admissions, number of hospital days etc 16 31 32 33 34 All reports provided at no cost are included In Attachment C to this Proposal Are you willing and able to provide the City or its consultant electronic claims data? What, if any, are the additional costs? Yes, we are able to provide the City or Its consultant electronic claims data Cost would be defined by the requirements What stop -loss camer have approved your company? NHSI has been approved by many stop -loss companies These companies include Acordia Benefits American United Life CNA Employers Reinsurance Corporation Equitable First Continental Life Group Management Services IDS John Alden Insurance Company Lincoln National Metropolitan Life Mutual of Omaha Mutual Security Life North American Life and Casualty Northwestern National Life Pacific Mutual Safeco Life Insurance Security Life of Denver Standard of Oregon Sun Life of Canada The Anthem Companies The Hartford Trans General Life and Casualty Group Union Labor Life Insurance Company Do your fees include the cost to produce check stock, postage, telephone service, and printing of forms? If not, what are your charges for such services? Our fees include check stock*, postage, long distance telephone calls, and printing of claim forms and EOes "If the NHSI Claim Account is used How often are claim reimbursement and administrative expense billings submitted? Form of transfer? Will the City collect all interest credits? Claim payments are made once per week At the same time the checks are mailed out, NHSI contacts the client to wire the funds needed to cover the claim checks into the claim checking account Any gains realized are minimal and used to offset the bank fees Administrative expense billings are submitted monthly 17 35 Describe how new members (employees) will be added to your system, terminated members inactivated and status changes made to current members The City is currently on-line and makes these changes directly 36 Do you agree to provide COBRA and Retiree administration? Yes, we will continue to provide COBRA and Retiree administration 37 In addition to COBRA, describe your support services in complying with the issuance of HIPAA certifications is there an additional charge for these services? We will produce HIPAA certificates for $10 00 per certificate or the City has on-line capability to look up eligibility information for production of the HIPAA certificates 38 What or how many hours per day will customer service representatives be available to assist callers with questions and problems? We are available for employee questions/problems from 8 00 a m -12 noon and 100pm-400pm 39 Describe what your coordination efforts would be in dealing with the City's utilization management and/or case management firm NHSI would provide any necessary information to the City's utilization management and/or case management firm in order to ensure that all cost containment interventions are implemented Case management firms usually provide us with specific cntena for case management referrals We then notify the appropnate case management vendor by Fax or by mail any time we become aware of a case that meets the vendors cntena IN TPA SERVICES SPECIFIC INFORMATION The claims administrator is to provide claims administration and payment and reporting services for all PPO POS, and/or EPO medical clam incurred pursuant to the City's Plan in effect on January 1 1999 and as amended from time to time The claims administrator must be able to adjudicate managed care claims The eligibility will be provided by the City Services Provide for the City the maintenance of necessary procedures to perform the following 1 receiving and processing claims for benefits under the benefit program including 2 certification of eligibility for medical claims and 3 provision of accounting services required in the processing of claims and recordkeeping as directed by the City and/or the stop -loss carrier 4 distribution of drafts in payment of claims after appropriate adjustment 5 prepare letters for distribution to participants with respect to denial of benefits similar to plan requirements 6 handle pending claims, including follow up with hospitals or providers in order to obtain information applicable to claims, screening of claims to avoid duplicate payment, maintenance procedures to assure consistency to clam -is payment in accordance with the plan of benefits and plan provisions for coordination of benefits 7 provide a monthly summary of medical claim payments to the City and its consultant The summary should include the following information a number of claims by line of coverage, including dollar amount claimed number of claims, total allowable charges, deductibles taken and amount paid by line of coverage All mus be provided on a monthly and year to -date basis by line of coverage each month b coordination of benefit savings c other specific claims data as requested by the City or the stop -loss carrier and d quarterly reports of claims exceeding 50% of individual stop -loss on a year-to-date basis The claims summary should be broken down into categories as directed by the City and will include Active, COBRA and Retiree claims data, dependent claims data and combined totals both on a monthly and year to -date basis Copies of the claims summary will be furnished to the City and other parties as directed by the City 31 18 Provide COBRA and Retiree administration to include compliance, mailing notices collection and posting of premiums, recordkeepmg of payments, changes in coverage eligibility, answering questions from participants, reporting and mailing payments and appropriate reports to City and follow up as needed 19 Coordinate special situations with the Utilization Management company to insure appropriate payment of claims 20 Provide support in compliance with issuing HIPAA certifications 33 himself of any other remedy at law or equity If the non -defaulting party commences legal or equitable actions against the defaulting party the defaulting party shall be liable to the non - defaulting party for the non defaulting party's reasonable attorney fees and costs incurred because of the default 13 Binding Effect This writing together with the exhibits hereto constitutes the entire agreement between the parties and shall be binding upon said parties their officers employees agents and assigns and shall inure to the benefit of the respective survivors heirs personal representatives successors and assigns of said parties 14 Indemnity/Insurance a The Service Provider agrees to indemnify and save harmless the City its officers agents and employees against and from any and all actions suits claims demands or liability of any character whatsoever brought or asserted for injuries to or death of any person or persons or damages to property arising out of result from or occurring in connection with the performance of any service hereunder b To the extent provided by law and by Article V Section 16 of the Fort Collins City Charter the City agrees to indemnify all actions suits claims demands or liability of any character whatsoever brought or asserted for injuries to or death of any person or persons or damages to property arising out of resulting from or occurring in connection with the City s negligent performance of any duty of the City under this Agreement However the City shall be entitled to all the protections afforded by the Colorado Governmental Immunity Act and as otherwise provided by law or equity c The Service Provider shall take all necessary precautions in performing the work hereunder to prevent injury to persons and property SA 10/97 4 d Without limiting any of the Service Provider's obligations hereunder, the Service Provider shall provide and maintain insurance coverage naming the City as an additional insured under this Agreement of the type and with the limits specified within Exhibit D consisting of one (1) page attached hereto and incorporated herein by this reference The Service Provider before commencing services hereunder shall deliver to the City's Director of Purchasing and Risk Management 256 West Mountain Avenue Fort Collins Colorado 80521 one copy of a certificate evidencing the insurance coverage required from an insurance company acceptable to the City 15 Entire Agreement This Agreement along with all Exhibits and other documents incorporated herein, shall constitute the entire Agreement of the parties Covenants or representations not contained in this Agreement shall not be binding on the parties 16 Law/Severabdity The laws of the State of Colorado shall govem the construction interpretation execution and enforcement of this Agreement In the event any provision of this Agreement shall be held invalid or unenforceable by any court of competent jurisdiction such holding shall not invalidate or render unenforceable any other provision of this Agreement 17 Special Provisions Special provisions or conditions relating to the services to be performed pursuant to this Agreement are set forth in Exhibit B Year 2000 Compliance Certificate and Indemnity consisting of two (2) pages attached hereto and incorporated herein by this reference and Exhibit E Confidentiality Agreement attached hereto and incorporated herein by this reference Also special provisions or conditions relating to the services to performed pursuant to this Agreement are set forth in Attachment A Questions to be answered by all proposers and Attachment C TPA Services Questions to be answered consisting of eighteen (18) pages attached hereto and incorporated herein by this reference SA 10/97 5 CITY OF FORT COLLINS COLORADO a municipal corporation By Qz � John Iv Fischbach i Manage gy r Ja s B O'Nedl II CPPO Dir t of Purchasing and Risk Management DateATTEST _ City Clerk AA PRp� RM ssistant City Attorn ATTESTZI -"4 P,4Uv-4gj CORPORATE SECRETARY SA 10/97 NATIONAL HEALTH SYSTEMS INC e CORPORATE PRESIDENT OR VICE PRESIDENT Date COD bar ae, \9q% (Corporate Seal) EXHIBIT A TPA SERVICES SPECIFIC INFORMATION The claims administrator is to provide claims admimstration and payment and reporting services for all PPO POS and/or EPO medical claims incurred pursuant to the City's Plan in effect on January 1 1999 and as amended from time to time The claims administrator must be able to adjudicate managed care claims The eligibility will be provided by the City Services Provide for the City the maintenance of necessary procedures to perform the following receiving and processing claims for benefits under the benefit program including certification of eligibility for medical claims, and provision of accounting services required in the processing of claims and recordkeeping as directed by the City and/or the stop -loss carrier distribution of drafts in payment of clauns after appropriate adjustment prepare letters for distribution to participants, with respect to denial of benefits similar to plan requirements handle pending claims, including follow-up with hospitals or providers in order to obtain information applicable to claims, screening of claims to avoid duplicate payment maintenance procedures to assure consistency to claims payment in accordance with the plan of benefits and plan provisions for coordination of benefits 7 provide a monthly summary of medical claim payments to the City and its consultant The summary should include the following information number of claims by line of coverage, including dollar amount claimed, number of claims total allowable charges, deductibles taken, and amount paid by line of coverage All must be provided on a monthly and year to -date basis by line of coverage each month, b coordination of benefit savings other specific claims data as requested by the City or the stop -loss carrier, and quarterly reports of claims exceeding 50% of individual stop -loss on a year to -date basis The claims summary should be broken down into categories as directed by the City and will include Active, COBRA and Retiree claims data, dependent claims data and combined totals, both on a monthly and Bear -to -date basis Copies of the claims summary will be furnished to the City and other parties as directed by the City furnish on a monthly basis a an updated list of those claims which have e-cceeded the individual stop -loss attachment point (including employee status sex age, diagnosis, amount paid and prognosis), a recap showing the accumulated status of the individual stop loss attachment point and clams turnaround time furnish on a auarterly and year-to-date basis by participant category a claim payment analysis of payments to providers, separately and combined, b claims by diagnostic JCD-9) category, as requested, c hospital claims data (admissions, number of days) by at least all surgical, medical, maternity and psychiatric/substance abuse admissions, and d claims by CPT-4 procedure code as requested 10 incurred date lag reporting capability, and provisions for reporting premiums to claims ratios 11 provisions for audit to see that plan policies and practices are followed as well as claim accuracy and claims processing efficiency 12 preparation and distribution on an annual basis of any forms which may be required by law from City ana their 13 totherequirements and prhone calls, os duresil or ersonal of the plan orsdetail ofethe benefits provided yees with respect 14 provide a contractually generated minimum average turn -around time of 95 % of all "clean' claims per week processed of not more than ten (10) working days which includes the period from the date the claim is received in your office to the date the check is issued to either participant or provider or notification of mabdity to immediately process the claim 15 maintain all files having to do with the claim payments including correspondence with the City and its participants 16 produce census data in chronological order by date of birth and including other information as specified, totals must be provided 17 assist in the procurement of check stock, claims forms identification cards, and other materials necessary to administer the medical plan 18 Provide COBRA and Retiree admimstration to include compliance, mailing notices collection and posting of premiums recordkeeping of payments changes in coverage eligibility answering questions from participants, reporting and mailing payments and appropriate reports to City and follow up as needed 19 Coordinate special situations with the Utilization Management company to insure appropriate payment of claims 20 Provide support m compliance with issumg HIPAA certifications