Pilot Test for EDI Transactions of Standards Adopted Under HIPAA

*****Please note: Deadline for submission has been extended to January 17, 2012.***** PILOT TEST FOR EDI TRANSACTIONS OF STANDARDS ADOPTED UNDER HIPAA This is a SOURCES SOUGHT NOTICE. This is NOT a solicitation for proposals, proposal abstracts, or quotations. The purpose of this notice is to obtain information regarding the availability and capability of qualified businesses that can provide development and implementation of a pilot to test transaction standards that have been or may be recommended for adoption to the Secretary of Health and Human Services (HHS), for mandatory use by health plans, health care clearinghouses and certain health care providers under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). 1.0 Background The original HIPAA legislation required the adoption of an initial set of standards for administrative and financial transactions between health plans, health care clearinghouses and certain health care providers. The transactions were for eligibility for a health plan, claims, claim payment, claim status, authorizations and referrals, enrollment in a health plan, and premium billing. The Affordable Care Act of 2010 requires adoption of additional and/or updated standards, as well as operating rules to support all adopted standard transactions. Existing process for the adoption of standards (new or updated) 1. Work groups within the Standards Development Organization (SDO) create or revise the implementation specification for each transaction in accordance with a regular schedule. Each updated version is voted on by various levels of work groups. Membership in the SDO is required for a vote, but each organization only gets one vote. 2. Updated and approved versions of the transaction standards are presented by the SDO to the Designated Standards Maintenance Organization (DSMO). The DSMO was named in the original HIPAA legislation in 2001, and is comprised of three SDOs and the code content committees. 3. The DSMO takes the updated and approved versions of the standards to the National Committee on Vital Health Statistics (NCVHS), suggesting that they recommend adoption. The NCVHS conducts industry hearings, presumably to obtain industry input on the new versions, and in turns makes a recommendation to the Secretary to adopt a standard or updated version of a standard. 4. The Secretary then publishes proposed and final rules to adopt the standard. Industry has two years in which to comply with the standard after publication of the final rule. For details on the adoption of the current set of transaction standards, visit the Regulations and Guidance page on the CMS website at www.cms.gov. History of standards adoption under HIPAA The regulations adopting the ASC X12 and NCPDP standards were first promulgated in 2001; the first compliance date was October 2003. The adopted versions were ASC X12 Version 4010 and NCPDP 5.1. In January 2009, HHS adopted updated versions of the two standards - ASC X12 Version 5010 and NCPDP D.0. Compliance is required by January 2012.. While both versions of the standards were adopted based on recommendations from the DSMO to NCVHS, and NCVHS to the Secretary, neither version was subjected to vigorous industry testing prior to adoption, and there were substantive implementation issues for X12 Version 4010, causing the need for addenda, followed by other issues for X12 Version 5010, which also resulted in addenda for several of the transactions. The need for the Version 5010 addenda is sometimes cited as responsible, in part, for the industry's delayed testing and implementation in the fall of 2011, necessitating another enforcement discretion policy for compliance with the standards. . In sum, HHS has adopted two versions of the X12 standards without any prior testing or validation; costing the private and public sector significant dollars. Again, in both cases, problems were identified with the transaction standards after they had been balloted by the SDO, recommended to the DSMO, to NCVHS, and then to the Secretary. These problems necessitated errata, addenda, a federal register notice outlining the problems and adopting a new sub version of the standard (4010A1), and most recently, the imposition of "enforcement discretion" for Version 5010 as a result of various technical issues identified late in the testing process. Within the next few years, HHS must adopt two new standards - one for electronic funds transfer (EFT) and one for electronic claims attachments. The EFT standard has been created by the financial services sector, and is maintained by the National Automated Clearinghouse Association (NACHA). Interestingly, there has been little controversy with this standard in its current use across all industry sectors; but it has not yet been in wide spread or consistent use in the health care industry. The other new standard is for electronic claims attachments. Before any recommendations for adoption of new standards or new versions of transaction standards, there should be a formal process for piloting and/or testing them for usability and usefulness to industry. For example, if the SDO and/or DSMO intend to propose adoption of a new version of the X12 standard, e.g. Version 6020, there must be data available to prove that this version is viable and acceptable to industry prior to adoption. 2.0 Requirements Overview and Operations The following provides potential responders with an overview of the types of support that would be required of the Pilot Test of Standards contractor. Note that although this is an extensive list, it is not meant to be all inclusive. Purpose and Scope The purpose of this project is to develop and execute a method of testing the updated versions of ASC X12 standard transactions before they are adopted under HIPAA and the Affordable Care Act (ACA). We wish to confirm the functionality, usability, interoperability and business usage of the standard transactions for the following: Eligibility, Claims, Claim Payment, Authorization, and Claim Status. The Contractor shall also maintain system hardware and software capabilities to perform required EDI testing and validation of transactions and operating rules. The deliverables for the pilot include the following activities, tasks, and documentation: Timeline We would like to conduct the pilot over the course of one year. We anticipate the following types of activities and anticipate additional input from interested parties. Phase I: Detailed Gap Analysis 1. Execution of gap analysis between new and old version of the standard 2. Identification of issues resulting from the gap analysis 3. Mapping of ASC X12 Version 5010 to Version 6020 4. Documentation of gaps and differences between ASC X12 Version 5010 to Version 6020 5. Documentation describing the strategy for testing the updated version and itemization of how issues will be documented when testing is conducted. Phase II: Development 1. Design and development of translators to conduct the mapping of the updated fields and requirements in ASC X12 Version 6020 2. Documentation of the issues and challenges identified in the design and development process Phase III: Execution and Quality Assurance 1. Documentation (user friendly, layperson terminology) of the gaps and barriers to use of each transaction in the new version 2. Recommendations for changes to the new version of the standard to accommodate industry business needs 3. Recommendations for changes to the standards development process 4. Recommendations for suggestions to improve the diversity of input to the standards development process 3.0 Capability Statement Information Please address your knowledge and experience within the last three (3) years and how you will demonstrate your expertise and experience in handling the mentioned requirements. Interested parties having the capabilities necessary to perform this requirement may submit capability statements via email to Jennifer Hennessy (jennifer.hennessy@cms.hhs.gov). Capability statements must demonstrate the minimum requirements outlined above. Capability statements shall also include the following information: Capability statements shall be limited to 15 pages and shall designate any/all teaming arrangements and the work proposed to be performed by each team member. Information about each team member shall be limited to not more than one page and should not represent more than 3 pages of the total submission. Business Information - 1. DUNS 2. Tax ID 3. Company Name 4. Company Address 5. Company Point of Contact, Phone and Email address 6. Current GSA Contracts with Schedule 7. Do you have a Government approved accounting system? If so, please identify the agency that approved the system. 8. Business Size Status (e.g., large business, small business, 8(a), woman owned, veteran owned, etc.) as validated via the Central Contractor Registration (CCR) for the applicable NAICS code (i.e. 541519). All offerors must be registered in the CCR located at http://www.ccr.gov/index.asp. 9. Point of Contact, Phone and Email address of individuals who can verify the demonstrated capabilities identified in the responses. Responses must be submitted not later than Friday, January 6, 2012. Capability statements will not be returned and will not be accepted after the due date. This notice does not obligate the Government to award a contract or otherwise pay for the information provided in response. The Government reserves the right to use information provided by respondents for any purpose deemed necessary and legally appropriate. Any organization responding to this notice should ensure that its response is complete and sufficiently detailed to allow the Government to determine the organization's qualifications to perform the work. Respondents are advised that the Government is under no obligation to acknowledge receipt of the information received or provide feedback to respondents with respect to any information submitted. Confidentiality. No proprietary, classified, confidential, or sensitive information should be included in your response. The Government reserves the right to use any non-proprietary technical information in any resultant solicitation(s). Questions concerning submission requirements may be directed to Jennifer Hennessy, Contract Specialist, via email at jennifer.hennessy@cms.hhs.gov or via phone at 410-786-2460. CMS will not entertain questions relating to contracting strategy.