Contractor Management

The Award Contract business process utilizes requirements, advanced planning documents, requests for information, request for proposal, and sole source documents to request and receive proposals, verify proposal content against Request for Proposal (RFP) or sole source requirements, apply evaluation criteria, designate contractor/vendor, post award information, entertain protests, resolve protests, negotiate contracts, and notify parties. In some States, this business process makes a recommendation of award instead of the actual award itself. NOTE: The State Medicaid Agency (SMA) requires billing agents, clearinghouses, or other alternate payee (as defined by the Secretary) to register.

The Close Out Contract business process begins with an expired contract or an order to terminate a contract. The business process ensures the obligations of the current contract are complete and the turnover to the new contractor proceeds according to contractual obligations.

The Manage Contract business process receives the contract award information, implements contract-monitoring procedures, updates contract if needed, and continues to monitor the terms of the contract throughout its duration.

The Produce Solicitation business process gathers requirements, develops a solicitation (e.g., Request for Information (RFI), Request for Quotation (RFQ), or Request for Proposals (RFP)), receives approvals for the solicitation, and releases for response.

The Inquire Contractor Information business process receives requests for contract (e.g., managed care, at-risk mental health or dental care, Primary Care Physician (PCP)) verification from authorized providers, programs or business associates, performs the inquiry, and prepares the response for the Send Outbound Transaction.

The Manage Contractor Information business process is responsible for managing all operational aspects of the Contractor (e.g., managed care, at-risk mental health or dental care, primary care physician, Recovery Audit Contractor (RAC)) data store. This business process receives a request for addition, deletion, or modification to Contractor information, validates the request, and applies the instruction. NOTE: Requires billing agents, clearinghouses, or other alternate payees (as defined by the Secretary) to register with Medicaid agency.

The Manage Contractor Communication business process receives requests for information, appointments, and assistance from contractors (e.g., managed care, at-risk mental health or dental care, primary care physician) such as inquiries related to modifications in Medicaid Program policies and procedures, introduction of new programs, modifications to existing programs, public health alerts, and contract amendments, etc. This business process includes the log, research, development, approval, and delivery of routine or ad hoc messages. The State Medicaid Agency (SMA) communications a variety of methods such as email, mail, publication, mobile device, facsimile, telephone, web or Electronic Data Interchange (EDI). NOTE: The Manage Contractor Communication business process handles current contractors by providing assistance and responses to individual entities, i.e., bi-directional communication. The Perform Contractor Outreach business process targets both prospective and current contractor populations for distribution of information regarding programs, policies, and other issues. Other examples of communications include: • Pay for performance communications - performance measures could affect capitation payments or other reimbursements. • Incentives to improve encounter information quality and submission rates.

The Manage Contractor Grievance and Appeal business process handles contractor (e.g., managed care, at-risk mental health or dental care, primary care physician) appeals* of adverse decisions or communications of a grievance. The Manage Contractor Communication business process initiates a grievance or appeal. The State Medicaid Agency (SMA) logs and tracks the grievance or appeal; it triages to appropriate reviewers; it researches it; it may request additional information; it schedules and conducts a hearing in accordance with legal requirements; and it makes a ruling based upon the evidence presented. Staff documents and distributes results of the hearings, and adds relevant documents to the contractor’s information. Agency formally notifies contractor of the decision. This business process supports the Manage Performance Measures business process by providing information about the types of grievances and appeals it handles; grievance and appeals issues; parties that file or are the target of the grievances and appeals; and the dispositions. This information used to discern program improvement opportunities, which may reduce the issues that give rise to grievances and appeals. Based on the appeal business process, if a contractor wins an appeal that impacts or clarifies a Medicaid State Plan, health plan, or health benefit this process sends that information to Maintain State Plan, Manage Health Plan Information or Manage Health Benefit Information business processes to modify the relevant policy or procedure. Disposition could result in legislative change requirements that will be communicated to lawmakers. NOTE: States may define grievance and appeal differently, perhaps because of state laws. *This business process supports grievances and appeals for both prospective and current contractors. A non-enrolled contractor can file a grievance or appeal, for example, when agency does not award a contract to contractor. Protests received from prospective contractors are addressed in the Award Contract business process

The Perform Contractor Outreach business process is responsible for sending information such as public health alerts, new programs, and/or modifications in the Medicaid Program policies and procedures. For prospective contractors (e.g., managed care, at-risk mental health or dental care, primary care physician), States Medicaid Agency (SMA) develops contractor outreach information for prospective contractors identified by analyzing Medicaid business needs. For currently enrolled contractors, information may relate to public health alerts, public service announcements, and other objectives. The SMA communicates contractor outreach information by a variety of methods such as email, mail, publication, mobile device, facsimile, telephone, web or Electronic Data Interchange (EDI). The SMA produces, distributes, tracks, and archives all contractor outreach communications according to state rules.