The Office of Personnel Management's (OPM) Federal Employees Insurance Operations (FEIO) group administers the Federal Employees Health Benefits (FEHB) Program for Federal employees, retirees, temporary Wildland firefighters and fire protection personnel, employees of Federally recognized Indian tribes, tribal organizations, and urban Indian organizations (tribal employer), and their eligible family members. FEIO is responsible for resolving disputed health insurance claims between members and their health insurance carrier. Two types of health insurance plans participate in the FEHB Program, Fee-for-Service (FFS) plans and Health Maintenance Organizations (HMO). FEIO is comprised of three Health Insurance Groups. Health Insurance 1 administers the Blue Cross and Blue Shield Service Benefit contract; Health Insurance 2 administers the remaining FFS plan contracts and experience rated HMO plan contracts; and Health Insurance 3 administers the community rated HMO plan contracts. Each health plan under the FEHB Program contracts with OPM to provide certain health benefits to all members enrolled in its participating plan. Under the terms of the contract, members are entitled to pursue claims disputes by following a formal dispute resolution process described in the plan's brochure. After giving the plan the opportunity to reconsider its decision, members may request OPM to review the plan's denial of benefits or benefit limitation. In some cases, because of the complexity of the medical issue/condition involved, it is necessary to obtain an external medical review advisory opinion from a medical consultant before OPM makes a final decision on the claim. Health Insurance 1 is responsible for monitoring the medical review services contract. Nurse consultants determine the medical specialty category and the appropriate medical specialist. The contractor is required to provide an expert opinion by medical specialists appropriate to the particular disputed claim under review. Specific tasks under this contract will be accomplished by work orders (work orders are equivalent to a "task-order contract" as defined in Federal Acquisition Regulation 16.501-1) issued by the Contracting Officer's Representative (COR), to be performed at the Contractor's place of business. The COR will provide to the Contractor in writing, a description of each specific proposed task to be performed under the contract, for example, review of disputed health benefits medical and dental claims, consultation services, or special projects. The contractor will provide medical and dental health benefits reviews of disputed claims and preservice requests (prior approval and precertification), consultation services, and special projects. OPM will determine the medical specialist category for each disputed claim and the Contractor will assign a medical specialist (Coding Specialist, M.D., D.O., D.D.S., or D.M.D.) appropriate for each disputed claim. The medical specialist will review the available case documentation for different categories of disputed medical services and will provide the Government a typed-written review analyses resulting from the evaluation of the case file in addition to a paper or electronic copy of all references cited in support of the analyses. The various categories of disputed medical services and issues requiring an advisory medical analysis include: Correct Coding Services, Medical versus Mental Treatment, Durable Medical Equipment, Cosmetic/Reconstructive Procedures, Medical Necessity, Dental Services, Maintenance Therapy, Custodial Care, Experimental/Investigational Services and Supplies, Emergency Treatment, HMO Issues, and Other Issues. The types of reviews include: First time review, cases requiring additional information, re-review for new clinical evidence, re-review for new question(s), other assigned work, and panel review for any of the aforementioned noted types of review and consultation services and special projects. Coding specialists must have nationally accepted credentials/certifications. The medical physician staff must have a degree in doctor of medicine, doctor of osteopathic medicine, doctor of dental surgery, or doctor of dental medicine from an accredited university. The medical physician staff must be licensed to practice medicine in a state in the United States of America, the District of Columbia, Puerto Rico, Guam, and the Virgin Islands. The Contractor's medical staff must be capable of providing an acceptable, understandable, type written document addressing the issue(s) relative to the work order under review. We will procure the proposed acquisition using full and open competition procedures. All responsible sources may submit a proposal, which we will consider. The proposed contract will an indefinite-delivery/indefinite-quantity contract with contract line items based on firm-fixed-prices. The performance period for the proposed contract is expected to be five years: a one-year base period plus four one-year options. OPM intends to issue a request for proposals (RFP) on or about November 16, 2012. The RFP and all documents relating to this requirement will only be available on the Federal Business Opportunities (FBO) website at https://www.fbo.gov. Interested parties are responsible for monitoring the FBO website for release of the RFP and all other documents relating to this requirement. We encourage interested parties to register on the FBO website for e-mail notification of all actions relating to the RFP and for the interested vendors list. After we release the RFP, we will give interested parties the opportunity to ask questions. We will include all questions and answers in an amendment to the RFP and post the amendment on the FBO web site. Proposals will be due on or about January 7, 2013. We anticipate awarding the proposed contract by April 2013. The current contractor for Federal Employees Health Benefits Medical Review Services is MAXIMUS Federal Services, Inc.
