Doula program – ITN #2022-01Healthy Start MomCare Network, Inc. Invitation to Negotiate ITN # 2022-01 Case Management Web-based Data System and Medical Billing

Doula Data System ITN Q&A

12-22-22 Q&A

General:

  1. Can you provide further details on how you plan to score the ITN proposals?

ANSWER: We have a diverse evaluation team that will review, in detail, all proposals that are received to determine the highest scoring bidders. Following the initial review and screening of the written proposals, using the selection criteria described below, more than one bidder may be invited to participate in the final selection process, which will include participation in an oral interview/demonstrations/presentation and/or submission of any additional information as requested.

  • The following criteria will be used in reviewing and comparing the proposals
    1. 10%–Responsiveness of the proposal to the submission requirements set forth in the ITN.
    2. 40%–The technical ability, capacity, and flexibility of the bidder to perform the contract in a timely manner and on budget, as verified by, e.g., the quality of any demonstration, client references, demonstrated success in projects with similar requirements including the following:
      • Application Software—features and functions of application software. There is a preference for a vendor with a product that may be implemented/modified in a timely manner vs. creating a new data system.
      • System Architecture—setup and system configuration. Ability to develop reports that may be run at the following levels: state, Healthy Start Coalition region, county, and doula provider.
      • Management—bidders’ experience, qualifications, approach, methods, and references.
      • Security—HITECH and HIPAA compliance, system tools, methods, and policies.
      • Change Management Process—process vendor uses for any needed changes to the data system including a separate testing site.
    3. 5%–HITRUST certification (not required)
    4. 10%–Experience with healthcare billing
    5. 10%–The financial viability of the bidder/author.
    6. 25%–The total estimated cost of the proposal solution. If the proposal contains itemized rates, per piece pricing, or commission-based pricing, HSMN reserves the right to calculate total contracted cost by calculating rates using future projected volume. Costs will be evaluated during the negotiation process only if a proposal is determined to be otherwise qualified.
  1. Is there a specific date by which the case management and medical billing systems need to be live for the doula’s to use? If possible, can you provide additional context around the quick timeline for a decision and go-live?

ANSWER: We have a goal to start in March 2023 but understand this may or may not be feasible which is one of the reasons why we issued an invitation to negotiate. We have separate grants/funders that are paying for doulas to be trained on a timeline. We want the doulas to be able to start services as soon as possible after training. We are open to recommendations from vendors on a feasible timeline. We would consider the possibility of starting with core case management functions and developing additional functionality with a longer timeline.

  1. Can you please confirm who the contracting entity will be?

ANSWER: Healthy Start MomCare Network, Inc., will be the contracting entity.

  1. Is there a budget or budget range that you can share for this project?

ANSWER: We do not have a budget as this is a new service for us. We anticipate starting smaller due to the client volume and increasing over time.

Scope:

  1. Are you currently using a case management or medical billing system today? If so, can you share more details?

ANSWER: We do not have a case management or medical billing system for doulas. We have a case management and billing system for Healthy Start services. These will be two completely separate programs with no requirement for integration or data sharing between the systems.

  1. How many doulas are expected to be a part of the program?

ANSWER: Please see #7 below. We hope to double the number of doulas each year for three years and then we may slow down on growth.

  1. Can you provide some additional information on the scope and responsibility of doulas? (e.g., are they restricted to a specific geographic area, or a cap on the number of patients they are able to provide services to? Do you have an estimate on the number of mothers/families that will be served in Year 1?)

ANSWER:

Doulas may have contracts with more than one Coalition. In this scenario, the Doula should have a separate user ID for each Coalition they work for. Caps will be monitored by programmatic representatives and no “stops” on intakes will need to be built into the data system. We will want the data system to provide the caseload list assigned to each doula.

Below are the projections for our first twelve months. We hope to double the number of doulas each year for two more years and then we may slow down on growth.


  1. Is the selected system also meant to serve as a replacement to the Connect coordinated intake and referral system?

ANSWER: No, the selected system will not be a replacement for Connect.

  1. Do you expect the remaining 15 coalitions to participate in the program and become users of both systems? If so, is there a timeline for when you anticipate that would occur?

ANSWER: We hope all Coalitions will provide doula services; however, due to two other new program launches that are just starting, we do not have a specific projection at this time.

Medical Billing:

  1. Is the CMS 1500 paper form the required billing format or would you be open to 837s (electronic forms)?

ANSWER: If the health plans agree, we are open to/prefer 837s. We are still in negotiations.

  1. Can you provide more information on health plan involvement/role in billing workflow?

ANSWER: We are in discussions/negotiations with Medicaid Managed Care Health Plans for contracts for Doula services/referrals. These Doula service claims will be submitted to each respective health plan. Some health plans have posted billing requirements on their websites, but these focused more for individual doulas providing services. We anticipate the process negotiated with each health plan will be more streamlined for HSMN’s network of doulas with the preference for an electronic process. Due to the tight timeline, if necessary, we would consider starting with paper CMS 1500 submissions and then upgrading to an electronic submission process. However, we would prefer to start with an electronic process if possible.

  1. Do any billable services require eligibility checks or individual service authorizations?

ANSWER: Yes, we will need to verify each client’s Medicaid eligibility on the date of service and verify pre-authorization by the health plan prior to submitting the claim.

  1. Can you expand on the billing response workflow requirements?

ANSWER: Below is our draft process that is subject to change during negotiations with the selected vendor.

  1. Upon receipt of a referral, the Doula conducts a pre-service intake that includes billing documentation on demographics and insurance information. She also informs the client that insurance pre-authorization is required.
  2. The Doula (or Doula Coordinator) requests pre-authorization from the health plan and documents the authorization number received in the data system.
  3. Five days prior to each scheduled encounter, the Doula (or Doula Coordinator) verifies the following:
    • Client Medicaid eligibility for the upcoming date of service and pre-authorization is documented in the data system.
  4. At each encounter:
    • Doula reviews with the mother her current demographics (name, DOB, address, phone) and insurance information (verifies client “gold card” number and eligibility dates) and updates the data system as needed.
    • Doula documents the services in the data system and completes the CMS 1500 pre-populated data system form with any needed information. The CMS 1500 paper form requires a provider signature. We are seeking clarification from health plans if we need to build the ability for the Doula or Doula Coordinator’s electronic signature or certification statement.
    • Doula Coordinators and/or a future state level quality assurance position will conduct regular, sample checks on claims submitted.
  5. IT Vendor:
    • Auto populates the CMS 1500 form based on the information entered by the doula. Billing codes will be fields in the data system listed in user-friendly terms for the doula to select.
    • If using 837 files, IT vendor uses the 270-271 process to verify eligibility prior to submitting the claims.
    • Provides a list of ineligible claims and denied claims for the Doula or Doula Coordinator to research and resubmit as needed.
  1. Can you expand on the reimbursement schedule details?

ANSWER: The health plan will send payments directly to HSMN. HSMN will negotiate with the selected IT vendor on the contract payment amount, frequency, and other terms.

  1. What services and/or outcomes are billable/reimbursable?

ANSWER: These vary by health plan. Some pay fee for service with doula service codes for each encounter provided by the health plan, and others may have a bundled rate for prenatal services, delivery, and/or postpartum visits.

  1. Does “process for payment submission” refer to processing payment transactions (i.e., moving money)?

ANSWER: No, the vendor will NOT be moving money. They will submit claims and provide Coalitions, doulas, and state level users with an appropriate list of claims and statuses: i.e., submitted, paid, ineligible, denied, pending.

  1. Can you expand on your expectation for number 6 (Communication with Organization, Coalition and Doula) in the Medical Billing requirements section?

ANSWER: This refers to notifying Coalitions and doulas of the status of claims. See number 16 above.

  1. Can you provide additional context on the types of health plans you expect to participate in reimbursement? Is this specific to only MCOs?

ANSWER: We will be working with the MCOs providing coverage for Medicaid eligible mothers. There are currently 8 MCOs.

12-19-22 Q&A

  1. Is there a contract term (1,3 years)?

ANSWER: Due to many unknowns in launching a new program, we anticipate this will be an annual contract with annual renewals or amendments based on program performance and vendor performance.

  1. Is there a projected client size for the first year?

ANSWER: Our estimates are based on the number of trained/available Doulas in each Coalition area. Below are the year one projections:


  1. Is the Doula program a standalone program or would there be other care coordination and screenings added into the case management system, such as depression or tobacco?

ANSWER: Services include standard doula services, case management, and care coordination defined as providing and tracking client referrals to community resources and medical care. We would like the data system to be able to document health screenings and assessments and create a family profile.

  1. Would you be working with all of the Health Plans?

ANSWER: We have presented the GROW Doula model to all Health Plans and are/will be meeting with each plan individually to negotiate potential contracts.

  1. Do we know if the services/claims will be the same across all Health Plans?

ANSWER: There may be some differences between health plans. All Doula services provided will adhere to the GROW Doula model and use the plan approved Medicaid billing codes for Doula services. The claims will need to be submitted on the standard CMS 1500 form to each Health Plan for billing.

  1. How will funds come back to HSMN billing through the Health Plan?

ANSWER: Members must have prior authorization (pre-certification) for Doula Services through their Health Plan. Claims are submitted on a CMS-1500 claim form in which the following information must be accurate: member demographics (Name, DOB, Medicaid ID, etc.), correct plan information, billing and rendering provider Medicaid ID number and NPI number, billing address cannot be a P.O. Box, Member Diagnosis, and procedure codes (approved Doula service codes). While most Health Plans have an online portal for submitting individual claims for Doula services, they all have a paper claims submission address as well. We would like the data system to auto populate as much of the CMS-1500 claim form as possible using information entered by the doulas, the Healthy Start MomCare Network, Inc., Medicaid ID and NPI numbers and billing address. Clean claims are paid or denied within 15 days for electronic or 20 days for paper from the date of receipt. The status of submitted claims can be tracked using the online portal. Each Health Plan has a process for disputing denied claims. CMS 1500 claim forms require a signature.

  1. How will referrals come in for Doula services?

ANSWER: Referrals may come from Coordinated Intake & Referral program through the local Healthy Start Coalitions, individual self-referrals, community referrals from other organizations, and Health Plan referrals.

12-13-22 Q&A

  1. Is the population of served women in the Doula program ever going to have any interaction with women that would be in Well Family System (Healthy Start case management system), for example, being universal prenatal and infant risk screens, that Healthy Start would serve in Coordinated Intake and Referral, or Healthy Start home visiting, or SOBRA referrals?

ANSWER: The Doula data system will be a standalone application. For purposes of the ITN, we are not requesting data system linkages with any other Healthy Start services or the universal risk screens from the Florida Department of Health.

  1. Will women in the Doula program receive care coordination independently as a stand-alone concept or could a Doula program woman be simultaneously served in a home visiting Program?

ANSWER: The Doula data system will be a standalone application. Doulas will provide referrals to community services (care coordination). A woman may receive doula services, Healthy Start home visiting, and Coordinated Intake and Referral services.

  1. What happens with the CMS-1500 once the data is collected in the form from the case? Is there any other processing beyond that, submission to a Health Plan, for example?

ANSWER: The selected vendor will need to submit the CMS-1500 form/data to each health plan based on the health plans’ specifications.

  1. Will, under any vendor arrangement, HSMN have an expectation that data, performance data and statistical data, etc., would be available in Well Family System (current Healthy Start Case Management System)?

ANSWER: The Doula data system will be a standalone application. HSMN will not expect to incorporate any doula performance or statistical data in the Well Family System.