|
|
|
Request For Proposal
For
Plan Administration and Provider Network
------------------------------------------
RFP Documents:
Submitted Questions
& Answers:
- The census (Appendix G) does not have the coverage type (single,
family, etc.) indicated on it. Could we have a revised census which indicates
coverage types?
NMMIP policies are all individual policies. The
census in Appendix G lists each individual enrollee, including any
members of the same family. It is
not common for more than one person in a family
to be covered. When that happens, each family member is issued a separate
policy.
However, we
do provide a break on expenses when, on the rare occasion,
there are three or more family
members covered, each with individual policies.
If there are three family
members, we reduce the deductible and out-of-pocket
requirements to that required for two members.
- Would MD Anderson Cancer
Center in Houston be a participating provider for someone on NMMIP?
It
is a requirement that the selected vendor provide a network that
allows access to some, but necessarily all, nationally
recognized centers
of excellence, such as Mayo Clinic, MD Anderson, Sloan-Kettering,
and so
forth. Since most of our enrollees come to us
when they are already sick, many already have established relationships
with
one
of these centers.
Since we are in the Southwest, the majority of
our enrollees who need
access to such centers are likely to currently
be going to MD Anderson or Mayo Clinic (Scottsdale). While we are
not mandating
which centers
are in a vendor's network, we are requesting
to know which
centers are in the network or how access to such centers
will be accommodated.
If,
for example, Sloan-Kettering in New York is the
only center in the network, this will be problematic for our population
in
New
Mexico
due to the
extended travel requirements, and will be taken
into consideration when evaluating the vendor's proposal.
- The census indicates there are 46 enrollees outside of New Mexico.
Are they covered by the pool and if so, will we need to provide network
coverage outside of New Mexico?
All NMMIP members are residents of New Mexico. In some cases, premiums
are paid by relatives, estates, trusts, and banks with out of state addresses.
Also, some NMMIP members live in border communities in New Mexico but have
mailing addresses in Texas or Arizona which may be just across the street.
There may also be a few members who are living with an ill relative out of
state for a short period of time, or who are working temporarily outside of
New Mexico. It is not necessary to provide network coverage outside of New
Mexico except for nationally recognized centers of excellence facilities as
discussed in the previous question.
- For the network provided,
are there mandated reimbursement levels for participating providers such as "Medicare"?
There are no mandated reimbursement levels for participating providers in the NMMIP provider network.
- Regarding Appendix J (Network Repricing Worksheet), for inpatient
claims repriced using a Per Diem rate, should we use the QTY (number
of units) on the Room and Board revenue code lines to determine the
length of stay?
Yes.
- Regarding Appendix J (Network Repricing Worksheet), for inpatient
claims, one UNM claim displays two DRGs. For repricing, which
DRG should we use?
Claim #9 should have been shown as two separate claims. Please
price the first 4 lines for DRG 410 and separately price the
remaining
17 lines for DRG 302.
- Regarding Appendix J (Network Repricing Worksheet),
for physician claims, there are anesthesia CPT codes included in
the list but
no time values (number of minutes) that were billed. Are the
Units a count of the time (minutes) that are necessary to reprice
these
codes?
For CPT 01810, price it based on 2 claims, each for 60 minutes of
time.
|
