Secure Exchange Data Software

Cheyenne River Health Center Performance Work Statement Background Indian Health Service (IHS), a federal agency within the Department of Health & Human Services (DHHS), is responsible for providing health services to American Indians and Alaska Natives. IHS provides a comprehensive health service delivery system for approximately 1.14 million American Indians and Alaska Natives who belong to 573 federally recognized tribes, in 35 states. IHS Headquarters is located in Rockville, MD, and is divided into twelve physical areas: Alaska, Albuquerque, Bemidji, Billings, California, Great Plains, Nashville, Navajo, Oklahoma, Phoenix, Portland, and Tucson. The Great Plains Area Office (GPAO) collaborates with its 19 IHS and Tribally managed service units to deliver healthcare to approximately 130,000 Native Americans residing in North Dakota, South Dakota, Nebraska, and Iowa. The Area Office’s service units include seven hospitals, eight health centers, and several smaller health stations and satellite clinics. The Cheyenne River Health Center (CRHC) falls under the GPAO. CRHC provides medical care for approximately 11,000 tribal members living on the Cheyenne River Sioux Tribe (CRST) Reservation and within the established Purchased/Referred Care Delivery Area (PRCDA). Serving a rural area, many patients that travel approximately 165 miles round-trip to receive care. The CRHC was built in 2011 to provide an expanded level of health care services specifically designed to meet the needs of the CRST population. The CRST, through a 638 contract with IHS, operates four satellite health stations that offer basic ambulatory services in the Cherry Creek, Red Scaffold, Swiftbird, and Whitehorse communities. Services at CRHC include: Emergency Room Department, Primary Care Clinic, Pharmacy, Physical Therapy, Radiology, Immunization Clinic, Inpatient Care, Laboratory, Purchased/Referred Care, Dietary, Eye Care, Well-Child Clinic, and Specialty Clinics: Audiology, ENT, MRI, OB/GYN, Podiatry and Telemedicine (Cardiology, Dermatology, Endocrinology, Internal Medicine, Hepatology, Nephrology, and Rheumatology). Purpose The Cheyenne River Health Center requires a secure exchange data software solution to provide connectivity to the Medicare DDE (Direct Data Entry)/FISS (Fiscal Intermediary Standard System), eligibility verification, eligibility searches, and perform third party insurance medical (emergency, inpatient, outpatient, and specialty clinic) claims (professional and facility) validation, approval and processing services for Medicare, Medicaid, VA and Commercial Payers for the Cheyenne River Health Center, providing confidentiality, authentication, integrity and non-repudiation for the Eagle Butte Hospital. IHS Headquarters mandates that payment systems are updated to reflect changes in medical practice and the relative value of services. Based on this, secure exchange-managed services are necessary for the medical claims process to ensure compliance. Work Schedule/Availability 24/7 availability of all payer eligibility verification and search services for health care center staff (with exceptions to scheduled service disruption) -- 1 of 6 -- Period of Performance Base Year: July 1, 2026, to June 30, 2027 Option Year One (1): July 1, 2027, to June 30, 2028 Option Year Two (2): July 1, 2028, to June 30, 2029 Option Year Three (3): July 1, 2029, to June 30, 2030 Option Year Four (4): July 1, 2030, to June 30, 2031 Place of Performance Cheyenne River Health Center Business Office/Patient Registration P.O. Box 1012 24276 166th Street Airport Road Eagle Butte, South Dakota 57625 Scope The contractor shall provide a secure exchange data software solution that includes technology for: • Connectivity to the Medicare DDE (Direct Data Entry) /FISS (Fiscal Intermediary Standard System) and automated claims status reporting, payment floor details, and other reports. • Eligibility verification for third-party payers to include Medicaid and Medicare. Anticipated monthly volume for Eligibility Checks: 100. • Eligibility results must include start and end dates of coverage. • Capability to search eligibility for third-party coverage for patients who do not provide or present insurance information. Anticipated volume for Insurance Searches per month: 1000. • Third-party insurance medical claims validation, approval, and processing services via a clearinghouse for Medicare, Medicaid, VA, and Commercial Payers (not limited to but including United Health Group) for the Cheyenne River Health Center. Anticipated volume for Claims Submission per month: 2,500. • Processes all claim types (professional and facility): Emergency, Inpatient, Outpatient, and Specialty Clinics; and provides both solicited and unsolicited claims status. Anticipated volume for Claims Status per month: 1000. • The software must provide rigorous and thorough claims rules and custom business rules. • Capability for self-monitoring usage of services for thresholds. • Training and support related to the scope of work – training provided either on-site or via teleconference. The software services shall comply with the following constraints: The software service shall not require Cheyenne River Health Center to install contractor software within the Cheyenne River Health Center or the Indian Health Service network. The service shall enable Cheyenne River Health Center to exchange data utilizing a Secure File Transfer Protocol (SFTP) as approved by the Indian Health Service Office of Information Technology. The service shall support Electronic Data Interchange (EDI) transactions and interactive Telnet application protocol sessions. -- 2 of 6 -- The service should support an unlimited number of users, and access should be workstation independent. The service shall not entail development of Health Insurance Portability and Accountability Act (HIPAA) transaction set translation or mapping processes, non-CMS or non-IHS- generated data or messages, …