Ill. Admin. Code tit. 8, pt. 755, exh. A
THE STATE OF ILLINOIS DEPARTMENT OF AGRICULTURE IS REQUESTING PROPOSALS TO FILL THE STATE'S NEEDS AS OUTLINED BELOW. PLEASE READ THIS ENTIRE PACKAGE AND SUBMIT PROPOSAL IN ACCORDANCE WITH THESE INSTRUCTIONS.
DESCRIPTION OF GOODS OR SERVICES
PROFESSIONAL ADVICE AND CLAIMS ADJUDICATION RECOMMENDATIONS FOR THE PAYMENT OF OUTSTANDING HEALTH CARE COSTS OF SOIL AND WATER CONSERVATION DISTRICT EMPLOYEES THAT WERE ELIGIBLE FOR REIMBURSEMENT FROM THE DISTRICTS' INSURANCE CARRIER, MID-CONTINENT MEDICAL BENEFIT TRUST.
SEND PROPOSALS TO: | IDENTIFY PROPOSAL AS: |
ILLINOIS DEPARTMENT OF AGRICULTURE CHIEF, BUREAU OF LAND AND WATER RESOURCES STATE FAIRGROUNDS P.O. BOX 19281 SPRINGFIELD, ILLINOIS 62794-9281 | CLAIMS ADJUDICATION PROPOSAL |
PROJECT CONTACT:
CHIEF, BUREAU OF LAND AND WATER RESOURCES
PHONE: 217-782-2172
TDD: 1-800-524-6858
SUBMIT A SIGNED ORIGINAL AND 3 COPIES OF YOUR PROPOSAL IN A SEALED CONTAINER.
PROPOSAL DUE __________________
This package consists of: Instructions; General Information; Basic Contract Terms and Conditions; Detailed Specifications; Technical Proposal; Intent to Propose.
EFFECTIVE IMPLEMENTATION DATE IS IMMEDIATE UPON SELECTION.
REQUEST FOR PROPOSAL
Claims Adjudication Services
for
Payment of Outstanding Health Care Costs
Administered by
Illinois Department of Agriculture
Issued by
State of Illinois
Illinois Department of Agriculture
Bureau of Land and Water Resources
Becky Doyle
Director
TABLE OF CONTENTS
Section I
Bidding Process
Section II
Contract Terms and Conditions
Section III
Minimum Qualifications
Section IV
Background
Section V
Department and Vendor Responsibilities
Section VI
Technical Proposal
Section VII
Proposal Submittal Requirements
Section VIII
Certifications
CLAIMS ADJUDICATION PROPOSAL
Section I
Bidding Process
In the RFP process the Department intends to make an award to the responsible Vendor(s) whose proposal is determined to provide the best value to the Department. The Department's needs are well defined, and the responses will be evaluated in accordance with predetermined criteria. Although the evaluation may result in a need to clarify proposals or to request "best and finals" from those in the zone of contention, the proposal as submitted will generally be the basis upon which a decision to award is made.
A response to this RFP will be referred to as a proposal.
The date, time and address for submitting proposals are shown on the instructions page. Please follow these directions carefully. Failure to comply is cause for rejection of the proposal.
Proposals, including amendments, may be mailed or hand delivered; but in either case, must be actually received as specified. Proposals received late will be returned unopened.
Proposals must be submitted in typed or printed form. Each original proposal and each of the copies must be signed in ink by an authorized representative of the Vendor. Amendments shall be signed by the same person who signed the proposal unless another person has been given signature authority, which must be verified.
The following describes the format in which bid proposals must be presented. Utilization of a standard format will facilitate the evaluation process. Each proposal must contain, at a minimum, the following items and must be presented in the following sequence: (Please provide the level of detail requested.)
NOTE: Price information must be submitted in a separate envelope within the sealed container. Price information is not to be shown in any other part of the proposal.
The Department reserves the right to reject any or all proposals, to request and evaluate "best and final" proposals, to award in whole or in part, and to waive minor defects. An individual proposal may be rejected if it fails to meet any requirement. The Department may seek clarification from a Vendor at any time, and failure to respond is cause for rejection. Any alternate proposal that meets the Department's needs may also be considered. Contract negotiations may be necessary after the award to formalize understandings.
Submission of a proposal confers no rights on the Vendor to an award or to a subsequent contract. This RFP process is for the Department's benefit only and is intended to provide the Department with competitive information to assist in selection of goods or services. All decisions on compliance, evaluation, terms, and conditions shall be made solely at the Department's discretion and made to favor the Department.
The Department reserves the right to modify requirements during the course of this contact by changing the scope of work, deliverables, and time frames, as well as addition or deletion of tasks to be performed or equipment to be provided and/or any other modification deemed necessary. Any changes in pricing proposed by the Vendor resulting from the proposed changes will be subject to acceptance by the Department. In the event prices are not acceptable to the Department, the contract may be subject to reprocurement based upon the new specifications.
Any inquiries shall be directed to the project contact. Do not discuss the proposal with any other State employee unless authorized by the project contact. All responses by the Department must be in writing to be binding.
To be considered, the Vendor must submit a definitive proposal, as requested by this solicitation, for the work to be accomplished under the proposed contract. Proposals which merely offer to conduct a program in accordance with the general requirements of the RFP may be considered non-conforming and may not be considered.
All costs associated with preparation and submission of a proposal are the responsibility of the Vendor. These costs shall not be chargeable to the Department by the successful or unsuccessful Vendors.
All proposals become the property of the Department and will not be returned except in the case of a late submission.
This RFP does not commit the Department to award a contract or to pay costs incurred in the submission of proposals, or costs incurred in making necessary studies for the preparation thereof, or to procure or contract for services or supplies. The Department reserves the right to reject any or all proposals, to negotiate with any Vendor(s) considered qualified, or to make award without further discussions.
In determining whether a Vendor is responsible, the Department will evaluate past performance, financial stability, references, compliance with applicable laws, business ethics and integrity, the perceived ability to perform completely as specified, and other relevant factors. Vendor must submit a current audited financial statement, annual or quarterly report, Dunn & Bradstreet rating or other acceptable proof of financial responsibility, and any other information to prove responsibility with the proposal to the address shown below. Additional information may be requested. Financial responsibility will be kept confidential unless otherwise required by law.
Illinois Department of Agriculture
Chief, Bureau of Land and Water Resources
State Fairgrounds
P. O. Box 19281
Springfield, Illinois 62794-9281
The Department will evaluate each response to the proposal using predetermined evaluation criteria. The general evaluation criteria, point ranking, formula, etc. will be disclosed to Vendors upon request, unless it is determined that disclosure could result in bias.
The Department's evaluation process includes the use of "best and final" proposals when deemed appropriate. The Department reserves the right, at any time prior to award of a contract and for any reasons, to request and consider "best and final" proposals from one or more of the Vendors who submitted a proposal. The number of Vendors allowed to submit "best and final" proposals and the scope of the "best and final" proposals shall be determined solely by the Department. No Vendor has a right to submit a "best and final." Any Vendor who is asked and fails to submit a "best and final" proposal need not be given further consideration. The purpose of the "best and final" proposal is to allow the Department to better define its needs; adjust specifications or other aspects of the procurement to reflect changed needs or perceptions or to address problems; or for any other purpose deemed appropriate by the Department.
The Department will select the proposal(s) which meets the Department requirements and provides the best value to the Department, price and other factors being considered, and which is submitted by a responsible Vendor(s). The Department reserves the right to award to multiple Vendors. All awards must be approved by the Department.
The Vendor(s) chosen for an award may be required to enter into contract negotiations with the Department. The Vendor(s) should be prepared to incorporate the Department request and the Vendor's proposal and any other written representations submitted with the proposal. If agreement cannot be reached to the Department's satisfaction, negotiations may begin with another Vendor(s). All contracts must be approved by the Department.
The successful Vendor(s) must not commence any billable work prior to the Department's execution of the contract. Work done before final execution is at the Vendor's risk.
Each Vendor shall designate one person who shall serve as contact for all matters pertaining to the proposal. In absence of such designation, the person who signs the proposal shall be deemed the Vendor contact.
Each entity the Department contracts with shall be contractually responsible for the total performance of its contract. Assignments for financing and subcontracting are allowable, but information on assignees and subcontractors must be provided. For any joint venture to be acceptable, one Vendor must take full contractual responsibility for performance. No assignment, subcontract, or joint-venture shall operate to increase any obligation. If a subcontractor is used to provide consulting services, the subvendor's name and amounts paid to the subcontractor must be disclosed.
This RFP and any subsequent contract shall be governed by the laws and rules of the State of Illinois which are incorporated into this RFP by reference.
Section II
Contract Terms and Conditions
The following terms and conditions are applicable to State Contracts. Negotiations may be necessary to further define these and other terms. Submission of a signed response to this solicitation indicates agreement to the terms and conditions contained herein, unless Vendor indicates an exception in writing.
The Department will make payments to the Vendor(s) in accordance with specified terms and conditions of the contract.
Obligations of the Department shall cease immediately and without penalty or further payment being required if in any fiscal year the Illinois General Assembly or federal funding source fails to appropriate or otherwise make available appropriate funds for this contract.
The Vendor, his employees, and subcontractors agree not to commit unlawful discrimination and agree to comply with applicable provisions of the Illinois Human Rights Act, the U.S. Civil Rights Act, Section 504 of the Federal Rehabilitation Act, and rules applicable to each. The Department of Human Rights' equal opportunity clause is specifically incorporated herein.
In compliance with the State and federal constitutions, the Illinois Human Rights Act, the U.S. Civil Rights Act, Section 504 of the Federal Rehabilitation Act, the Department of Agriculture does not unlawfully discriminate in employment, contracts, or any other activity.
The Americans with Disabilities Act ( 42 U.S.C. 12101 et seq.) and the regulations thereunder ( 28 CFR 35.130) (ADA) prohibit discrimination against persons with disabilities by the Department, whether directly or through contractual arrangements, in the provisions of any aid, benefit or service. As a condition of receiving this contract, the undersigned Vendor certifies that services, programs and activities provided under this contract are and will continue to be in compliance with the Americans with Disabilities Act (ADA).
The Department does not assume any liability for acts or omissions of the Vendor, and such liability rests solely with the Vendor. The Vendor shall carry public liability, casualty, and auto insurance in sufficient amount to protect the Department from liability for acts of the Vendor. In addition, the Vendor shall carry worker's compensation insurance, if applicable, in the amount required by law.
The Vendor shall save and hold harmless and indemnify the Department against any and all liability, claims, and costs of whatever kind and nature for injury to or death of any person or persons and for loss or damage to any property occurring in connection with or in any way incident to or arising out of the use, service, operation, or performance of work under the terms of this contract resulting from the negligent acts or omissions of vendor, of any employee, agent, or representative of Vendor or subvendor. The Vendor is not responsible for consequential damages.
Vendor agrees that Vendor personnel will not divulge or release data or information developed or obtained in connection with the performance of the contract, unless made public by the Department, except to authorize Department personnel or upon written approval of the user agency's project manager.
Within 30 days of receiving notice from the Department, the Vendor will provide to the Department all records related to processing and validating claims and making its recommendations to the Department. Failure to maintain the books, records, and supporting documents required by this Section shall establish a presumption in favor of the Department for the recovery of any funds paid by the Department under the contract for which adequate books, records, and supporting documentation are not available to support their purported disbursement.
Effective July 1, 1993, the Vendor or Vendors shall have written sexual harassment policies that shall include, at a minimum, the following information:
Any breach of this contract by the Vendor will allow the Department to cancel without penalty and have any other available relief.
This contract shall be governed by the laws and rules of the State of Illinois which are incorporated into this RFP by reference.
Section III
Minimum Qualifications
In order for a Vendor to qualify to submit information and a proposal, it should be able to meet all of the following, or the equivalent of such requirements. It is at the discretion of the Department to determine the extent to which the following qualifications are required for award of the contract or that failure to meet these qualifications may disqualify any Vendor. The Department intends to evaluate each proposal in its entirety.
In order for a Vendor to qualify to submit a proposal for Claims Administration Services, the following minimum qualifications must be met:
* Licensure/Certification. The Vendor must be licensed or registered with the Illinois Department of Insurance as a third party administrator as required by applicable Illinois law.
* Experience. The Vendor must have a minimum of two years of satisfactory experience in claims administration.
* Financial Condition. The Vendor must demonstrate sound financial condition and good business practices. Accounting methods must maintain a clear distinction between claims administration performed under contract for the Department and other business.
* Reports. The Vendor must agree to furnish the Department with timely reports in mutually agreed upon formats.
* Customer Service/Communications. The Vendor must provide a telephone number for claims inquiries which will be available to all employees during regular business hours.
* Medical Review. The Vendor must have medical professionals with appropriate credentials to review questionable claims. Medical experts must be present for final review/fact-finding meetings at the request of the Department.
* Pricing Screens. The Vendor must have available and provide on request all pricing screens and maximum allowable reimbursement levels per procedure code, provider, and service.
* Background Check. As a condition of award and as a continuing condition of any resulting contract, the Department reserves the right to conduct background checks of Vendor, its officers, and of those employees or agents who would perform the required services to determine suitability for performing this contract. Vendor shall complete or have completed an authorization for release of personal information that indemnifies both the Department and the provider of the information.
Section IV
Background
The Department is requesting proposals for claims administration services to assist the Department in carrying out responsibilities pursuant to 70 ILCS 405/6(11) regarding the payment for outstanding health care costs of Soil and Water Conservation District employees. Soil and Water Conservation District employees, their dependents, and spouses had health care coverage provided by Mid-Continent Medical Benefit Trust (Mid-Continent). In late 1995, Mid-Continent developed financial difficulties that ultimately resulted in the non-payment of claims for provider services estimated to be in excess of $172,000. The Department has been granted legal authority to pay these outstanding health care costs and is seeking a qualified Vendor(s) to determine the amount of each claim to be paid based on standard claims adjudication practices.
CONTRACT:
This contract will be effective through ___________. The contract between the Department and the Vendor will detail the services included in the administrative services fees proposed. Any additional services provided will be separately identified and negotiated.
Section V
Department and Vendor Responsibilities
The following are Department and Vendor responsibilities as indicated, applicable to any contract that may be offered as a result of this proposal. Indicate understanding and acceptance of each of the following:
DEPARTMENT RESPONSIBILITIES:
The Department will perform the following functions:
VENDOR RESPONSIBILITIES:
The Vendor will perform the following functions:
Section VI
Technical Proposal
Please address each of the issues in full detail in the order below, repeating the question, followed by the response.
The primary responsibility of the Vendor is to process claims accurately and in a timely manner after the Department has furnished eligibility information. The Vendor will be expected to receive all claims directly from the Department, obtain supplemental information as needed to process claims, recommend to the Department the amount to be paid, and issue an EOB to the Department. The Department will mail the EOB along with the check to the applicable Soil and Water Conservation District.
Describe the customer service function that will be included in this Contract.
Provide a final report listing all claims processed and/or any other reports deemed necessary by the Department within 30 days of expiration of the Contract between the Department and the Vendor.
Section VII
Proposal Submittal Requirements
The purpose of these specifications is to provide relevant information to Vendors interested in submitting proposals to make recommendations on the adjudication of claims pursuant to the authority granted under 70 ILCS 405/6(11) concerning the payment for outstanding health care costs of Soil and Water Conservation District employees.
Objectives in Soliciting Proposals:
The Department has two primary objectives in soliciting proposals for claims processing:
* to obtain professional advice and claims adjudication recommendations;
* to obtain these services at a competitive cost.
General Submission Guidelines:
The date, time and address for submitting proposals are shown on the instructions page of the Request for Proposal. Please follow these directions carefully. Failure to comply is cause for rejection of the proposal. Proposals, including amendments, may be mailed or hand delivered; but in either case, must be actually received as specified. Proposals received late will be returned unopened.
Bidders will be required to present the data required by this RFP in an organized format which includes the minimum Qualifications (and signed Certifications), the Technical Proposal (and References) and the Fee Quotation. Utilization of a standard format will facilitate the evaluation. Bidders must present complete and self-explanatory information as required by this RFP. Information provided by Vendors will first be reviewed for minimum qualifications. Vendors meeting the minimum requirements will be further evaluated using the content of the Technical Proposal, based on its completeness and scope. The fee quotation will be reviewed after potential Vendors have been evaluated for overall quality and service level proposed.
Proposal Components:
To be considered for selection, a signed original and three (3) copies of sealed proposals must be submitted in a format organized by three major sections:
* Minimum Qualifications documentation (and signed Certifications)
* Responses to questions in the Technical Proposal and References
* Fee Quotation
Minimum Qualifications Documentation:
This section of the proposal should provide all pertinent licensure, registration, and experience information. The official corporate position on each of the qualifications listed should be stated. Any deviation from the qualifications should be clearly identified and alternatives suggested for the Department's consideration.
Certifications:
A copy of the Certifications section should be completed and submitted with the proposal. An original signature(s) must appear on the last page of the completed Certifications section.
Technical Proposal:
The Technical Proposal is to be organized in a sequence to follow the order of the major topics of Section VI of this RFP. Please repeat the question, followed by the appropriate response. The Technical Proposal should contain descriptions of how the prospective Vendor intends to service the account.
References should be provided as the final part of the Technical Proposal.
Fee Quotation:
Three copies of the fee quotation must be submitted in a separate sealed envelope. Specify any additional fees applicable. Please identify the service and the associated charges.
Supplemental Information:
The response to the RFP must be received by the Department by 5:00 p.m. C.S.T., _________. Send the response to:
Illinois Department of Agriculture
Chief, Bureau of Land and Water Resources
State Fairgrounds
P. O. Box 19281
Springfield, Illinois 62794-9281
Section VIII
Certifications
Name: _____________________________________________________
Taxpayer Identification Number:
Social Security Number ________________________________________
or
Employer Identification Number __________________________________
(If you are an individual, enter your name and SSN as it appears on your Social Security Card. If completing this certification for a sole proprietorship, enter the owner's name followed by the name of the business and the owner's SSN. For all other entities, enter the name of the entity as used to apply for the entity's EIN and the EIN.)
Legal Status (check one): | ||
Individual | Governmental entity | |
Ownership of Sole Proprietorship | Nonresident alien individual | |
Partnership | Estate or legal trust | |
Tax-exempt hospital or extended care facility | Foreign corporation, partnership, estate or trust | |
Corporation providing or billing medical and/or health care services | Other | |
Corporation NOT providing or billing medical and/or health care services | ||
Vendor/Grantee: For the purpose of this certification, "grantee" or "vendor" means a corporation, partnership, or other entity with twenty-five (25) or more employees at the time of issuing the grant, or a department, division, or other unit thereof, directly responsible for the specific performance under a contract or grant of $5,000 or more from the State.
The vendor/grantee certifies and agrees that it will provide a drug free workplace by:
Individuals: If Vendor is an individual, or an individual doing business in the form of a sole proprietorship, the individual certifies that the individual will not engage in the unlawful manufacture, distribution, dispensation, possession or use of a controlled substance in the performance of the contract. Vendor certifies that it will not engage in the unlawful manufacture, distribution, dispensation, possession or use of a controlled substance in the performance of the contract. This requirement applies to contracts of more than $5,000.
Vendor, its employees and subcontractors, agree not to commit unlawful discrimination and agree to comply with applicable provisions of the Illinois Human Rights Act, the Public Works Employment Discrimination Act, the U.S. Civil Rights Act and Section 504 of the Federal Rehabilitation Act, and rules applicable to each. The equal employment opportunity clause of the Department of Human Rights rules is specifically incorporated within this RFP.
The Americans with Disabilities Act ( 42 U.S.C. 12101 et seq.) and the regulations thereunder ( 28 CFR 35.130) (ADA) prohibit discrimination against persons with disabilities by the State, whether directly or through contractual arrangements, in the provision of any aid, benefit or service. As a condition of receiving this contract, the undersigned Vendor certifies that services, programs and activities provided under this contract are and will continue to be in compliance with the ADA.
The undersigned acknowledges and agrees that each of the certifications or amendments shall be incorporated into and made a part of the invitation for bids, request for proposals, agreement, contract, amendment, renewal or other similar document to which these certifications are attached.
VENDOR
NAME ________________________________________________________
BY ___________________________________________________________
TITLE _________________________________________________________
PROPOSAL COVER SHEET CLAIMS ADJUDICATION PROPOSAL
Submitted by:
_______________________________________________________________
Firm
_______________________________________________________________
By
_______________________________________________________________
Title
_______________________________________________________________
Signature
_______________________________________________________________
Date
_______________________________________________________________
Telephone Number
_______________________________________________________________
Toll-free Number
_______________________________________________________________
Fax Number
RETURN A SIGNED ORIGINAL AND THREE (3) COPIES OF PROPOSAL TO:
State of Illinois
Department of Agriculture
Chief, Bureau of Land and Water Resources
State Fairgrounds
P. O. Box 19281
Springfield, Illinois 62794-9281
PROPOSAL DUE:___________________
Ill. Admin. Code tit. 8, pt. 755, exh. A