DHHS, Aberdeen Area Indian Health Service, 115 4th Avenue Southeast, Room 309 Federal Building, Aberdeen, South Dakota 57401

Q -- TO PROVIDE PAYMENT INTEGRITY, QUALITY OF CARE, AND UTILIZATION MONITORING SERVICES SOL RFP 99-03 POC Ronald J. Sieler, Contract Specialist, and Ronda M. Longbrake, Contracting Office at 605-226-7567 Q -- Sources are being sought for Native American, Buy-Indian certified contractors to provide review services for the Contract Health Services (CHS) payment integrity, quality of care, and utilization monitoring services through the implementation of a retrospective compliance and quality monitoring audit program. The contractor shall assist the AAIHS in the review of payment information for approximately 4300 hospital admissions in the Aberdeen Area states of SD and ND. Qualifications necessary for this proposed contract includes the availability of a Medical Director on staff to interact with medical societies, peer groups, and other industry groups to keep abreast of medical practices and technology changes; oversees the development of contractor policy, including when policies or updates are needed and the development of written guidelines used by contract personnel; oversees the use of subcontracted or part-time medical professional such as specialty physicians; make claim and quality of care determinations when warranted; advise AAIHS Contract Health Services (CHS)on national coverage and payment issues; and develop and conduct case management training to AAIHS providers. The contractor shall also utilize the Medical Director for his expertise when performing any of its other tasks, (i.e., problem identification, fraud case development, etc.) The Medical Director shall be a board certified doctor of medicine or doctor of osteopathy with a current state license. The Medical Director shall have extensive knowledge of the CHS Program, particularly the coverage and payment rules of the CHS Program. Prior work experience in the health insurance industry, a utilization review firm, or other health care claims processing organization in a role that involved developing coverage or medical necessity policies and guidelines. The Medical Director must have experience in prospective, concurrent, or retrospective utilization review, or health care services. It is required that the Medical Director have publicrelations experience such as working with physician groups, private and public hospitals, beneficiary groups, state healthcare programs, and/or congressional offices. If you are a certified Indian owned contractor capable of providing these services based on the agency established schedule and have the professional qualifications to provide services, you are requested to respond in writing with a copy of your approved certification of Indian ownership to the address listed above, or you may telefax your request to 605-226-7669. Responses must be received within 10 calendar days from the date of appearance of this sources sought announcement in the CBD. Posted 03/04/99 (W-SN305224). (0063)

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