Opportunity Detail

Questions and Answers

Single Pharmacy Benefit Manager
Document #:  ODMR20210020


Question:   In the RFPs Attachment Four Subsection on Work and Contract Administration (Section 6.4.2) there is a paragraph on Suspension and Terminations requirements that the SPBM must fufill to ODM. Why doesnt this paragraph specifically state that the Contractor must pay all claims submitted up to the date of suspension and termination by network pharmacies for payment under the requirements for "transparent pass-through method" of payment (know as "the tail claims at the end of a PBM contract)?

Answer:   The purpose of the Question and Answer process is to enable offerors and interested parties to obtain clarification about the procurement requirements in order to prepare a proposal. The question's portrayal of the RFP is not accurate. The SPBM responsibilities in the event of contract suspension and termination is addressed in RFP Base - Suspension and Termination starting on page 56. Specifically, "In the event of termination whether for cause or without cause, the Contractor agrees to fulfill all duties and obligations as required under OAC Chapter 5160-26, the Contract, and any provider agreements related to the provision of services for the Medicaid population during periods of time when the Contractor was under contract with ODM. Such duties and obligations include the performance of ongoing functions and the submission of all outstanding reports and deliverables as identified in the Transition Plan. The Contractor must fully cooperate with ODM and ODM’s designee(s) to support a seamless transition of members and administrative responsibilities. The Contractor must participate in any meetings, workgroups, or other activities as requested by ODM to support the transition. The Contractor must comply with financial and insurance requirements until ODM provides the Contractor written notice that all continuing obligations under this Contract have been fulfilled. At the option of ODM, the Contractor will be required to submit a refundable monetary assurance to ensure the Contractor’s successful completion of its responsibilities".

Date: 8/28/2020

Inquiry: 78155


Question:   In the RFPs Attachment Four Subsection on Work and Contract Administration (Section 6.4.2) there is a paragraph on Insurance and Limit of Insurance requirements. As is usually a standard public procurement practice, why isnt ODM in this section of the RFP: 1) requiring the selected SPBM Contractor to submit a surety bond for the full amount of the 2 year contract and 2) requiring the renewal of a 2 year surety bond for the value of any subsequent 2 year renewal of a contract?

Answer:   The purpose of the Question and Answer process is to enable offerors and interested parties to obtain clarification about the procurement requirements in order to prepare a proposal. This question is not seeking such clarification. Please refer to RFP Base - Section 6.4.2 for information about insurance requirements.

Date: 8/28/2020

Inquiry: 78156


Question:   In the RFPs Purpose Section (Section 1.1), ODM uses the term "transparent pass -through method of payment of ingredient costs and fees" for the SPBM to pay claims but does not define the term or establish the type of methodology that the SPBM must use to ensure it is "transparent pass-through", such as published national average acquisition costs (NADAC) and a survey based Cost to Dispense (COD) professional fee. Given the vague reimbursement standard in the RFP, how will ODM prevent the SPBM from instituting post point of sale (POS) recoupments (i.e. "clawbacks") of MMC prescription claims where there is no documented proof of Medicaid fraud, thereby violating the requirement for "transparent pass-through method of payment"? Why doesnt the RFP prohibit post POS recoupment by the SPBM except in instances where there is documented proof of fraud?

Answer:   The purpose of the Question and Answer process is to enable offerors and interested parties to obtain clarification about the procurement requirements in order to prepare a proposal. This question is not seeking such a clarification. Please note that determining the ingredient cost and fees paid to pharmacies is not part of the Scope of Work of the SPBM. ODM will be establishing the ingredient costs and fees that will be paid to pharmacies. ODM will be making a directed payment to the pharmacies through the SPBM. The SPBM will not be retaining any portion of those payments. The SPBM will be paid an administrative fee for processing pharmacy claims and making the payments.

Date: 8/28/2020

Inquiry: 78158


Question:   In the RFPs Attachment Four Subsection on Work and Contract Administration (Section 6.4.2) there is a paragraph on audits requirements on the SPBM Contractor cover requirements for compliance with any state audit. Why isnt there a requirement in this paragraph or anywhere else in this section for Quarterly audits by the ODM of the SPBM data for compliance with full rebate pass through back to the State of Ohio? Why doesnt this section specify that the costs associated with any audits conducted by ODM or its duly authorized representatives are to be paid by the SPBM Contractor?

Answer:   The purpose of the Question and Answer process is to enable Offerors and interested parties to obtain clarification about the procurement requirements in order to prepare a bid. This group of questions is not asking for clarification of requirements. For more information about auditing requirements, please refer to Template B - Terms and Conditions - SLA 26 (page 24) and Supplement 7 - Draft Managed Care Rule, Section 9 (page 43) for information about audit compliance expectations of the SPBM. The SPBM will not be managing the Medicaid Drug Rebate program (refer to Supplement 1 - Page 1). "The SPBM will be barred from participation in financial benefits such as drug rebates, rate setting, discounts, clawbacks, fees, grants, chargebacks, or other incentive payments" (Supplement 1 - Page 2).

Date: 8/28/2020

Inquiry: 78154


Question:   The Section of the RFP on Attachment One: Evaluation Criteria (Section 6.1) on Minimum Mandatory Requirements has a requirement for an Offeror to demonstrate it has experience within the last three (3) years as the PBM contractor to at least three (3) governmental or private health entities with contract sizes similar to ODMs SPBM contract envisioned in the RFP? How is this requirement: 1) not discriminatory against other PBMs that are not currently serving Ohios Medicaid managed care program and 2) unfairly favor 2 national PBMs currently serving Ohios Medicaid managed care program that are being investigated and sued by the State of Ohio?

Answer:   The purpose of the Question and Answer process is to enable offerors and interested parties to obtain clarification about the procurement requirements in order to prepare a proposal. This question is not seeking such clarification. Please refer to Inquires 77959, 77982, and 77891.

Date: 8/28/2020

Inquiry: 78153


Question:   The Section of the RFP on Attachment One: Evaluation Criteria (Section 6.1) on Minimum Mandatory Requirements has a requirement for an Offeror to demonstrate communcations protections with other entities that would create conflicts of interest. How can ODM ensure that communications does not happen with a SPBM Offeror that owns, controls or has a contractual relationship with a retail pharmacy chain, its specialty pharmacy or a Long Term Care (LTC) pharmacy?

Answer:   The purpose of the Question and Answer process is to enable offerors and interested parties to obtain clarification about the procurement requirements in order to prepare a proposal. This question is not asking for such clarification. Note that it is the responsibility of the Offeror to demonstrate that no conflict of interest exists. ODM will review in detail all conflict mitigation plans.

Date: 8/28/2020

Inquiry: 78152


Question:   The RFPs section on Determination of Responsibility (Section 4.9) states that ODM will consider in evaluating and awarding a contract an Offerors "past conduct on previous contracts, past performance on previous contracts". Given that the State of Ohio is current in litigation against two PBMs that services several Ohio MMCOs contracts for Medicaid managed care prescription benefits, why doesnt the RFP include a prohibition or at least deductions in the evaluative scoring of a bid from any SPBM that is the subject of investigation or litigation by the State of Ohio for activities related to their management of any Ohio publicly funded prescription benefit program?

Answer:   The purpose of the Question and Answer process is to enable Offerors and interested parties to obtain clarification about the procurement requirements in order to prepare a proposal. This question is not asking for clarification but instead is asking about the State's intentions during the scoring process. Note that the RFP and Ohio statutes provide ODM with significant flexibility when considering offerors. Among other provisions, Section 4.9 of the RFP states in part, "The factors that the state agency or political subdivision shall consider in determining whether an Offeror on the contract is responsible include the experience of the Offeror, the Offeror's financial condition, conduct and performance on previous contracts, facilities, management skills, and ability to execute the contract properly." See also Ohio Revised Code section 9.312.

Date: 8/28/2020

Inquiry: 78151


Question:   the RFP process of the RFP (Section 1.4) states that the final awarded contract for a SPBM can be extended for up to three (3) additional 2 year terms, which equates to it being potentially an 8 year contract. Given that many circumstances can change during that timeframe, why doesnt the OMD limit the contract to one (1) 2 year term extension which would give ODM time to procure for such future services that would allow the State of Ohio to take advantage of future market forces and competition for a SPBM?

Answer:   The purpose of the Question and Answer process is to enable offerors and interested parties to obtain clarification about the procurement requirements in order to prepare a proposal. Inasmuch as this question is asking about the State's intention, the question is not relevant to the requirements. Please note that the RFP expressly authorizes ODM to re-procure in two years. An extension is not required. However, an extension is allowed if ODM determines that the selected vendor provides a valued service. This will allow ODM to take advantage of future market forces and possible competition for a new SPBM. Additionally, Section 6.4.2 of the RFP provides, “ODM also may terminate this Contract in full or in part for its convenience and without cause or if the Ohio General Assembly fails to appropriate funds for any part of the Project.”

Date: 8/28/2020

Inquiry: 78150


Question:   the RFP Purpose (Section 1.1) states that ODM will require the SPBM to use "transparent pass-through method of payment of ingredient cost and fees" but does not define the term. Why doesnt the RFP define "transparent pass-through method of payment of ingredient costs and fees" as the national published average acquisition cost (NADAC) of each covered drug and the state surveyed cost to dispense (COD) based professsional pharmacy fee? Will ODM add this definition to the RFP? Will ODM require that SPBM bidders submit their "transparent pass-through method of payment" with their bid and subject the methodology to ODM approval in awarding the bid?

Answer:   The purpose of the Question and Answer process is to enable offerors and interested parties to obtain clarification about the procurement requirements in order to prepare a proposal. This group of questions is not seeking such clarification. Please refer to the RFP for the RFP requirements. Note that determining the ingredient cost and fees paid to pharmacies is not part of the Scope of Work of the SPBM. ODM will be establishing the ingredient costs and fees that will be paid to pharmacies. ODM will be making a directed payment to the pharmacies through the SPBM. The SPBM will not be retaining any portion of those payments. The SPBM will be paid an administrative fee for processing pharmacy claims and making the payments.

Date: 8/28/2020

Inquiry: 78149


Question:   Section 4.5 (Technical Evaluation) states that ODM may seek input on the Single PBM proposal bids received from other state personnel and "end users of the Work". Does that ODM seeking input from: 1) OH State Attorney General, the OH Auditor General and the Ohio Legislature Joint Medicaid Oversight Committee (JMOC) that have reviewed and reported on MMC PBM actions and 2) MMC prescription patient recipeients and pharmacy providers?

Answer:   The purpose of the Question and Answer process is to enable offerors and interested parties to obtain clarification about the procurement requirements in order to prepare a proposal. Inasmuch as this question is asking about the State's intention, the question is not relevant to the requirements.

Date: 8/28/2020

Inquiry: 78148


Question:   SPBM Template C.1., Contractor Overview Tables 1 and 2: Offerors and subcontractors are required to provide revenue-related information on rows 7 through 10 of Tables 1 and 2. Will the State waive this requirement for privately-held organizations since this information is typically treated as confidential and proprietary?

Answer:   The information requested in Tables 1 and 2 consists of basic financial information. Such information is not a trade secret. It is required for ODM to determine the Offeror is financially responsible. Section 4.11 states, "Part of ODM’s determination of an Offeror’s [responsibility] may include the Offeror's financial ability, including parent organization, to perform the Contract. This RFP may require the submission of audited financial statements from all Offerors in their Proposals, but if this RFP does not make this a requirement, ODM may still insist that an Offeror submit audited financial statements for up to the past three (3) years, if ODM is concerned that an Offeror may not have the financial ability to carry out the Contract. Also, ODM may consider financial information other than the information that this RFP requires as part of the Offeror’s Proposal, such as credit reports from third-party reporting agencies."

Date: 8/28/2020

Inquiry: 78105


Question:   Supplement 6:42CFR 438.330: Question: While it is clear that the Single PBM Contractor will have an overall focus on quality improvement and certain clear-cut specific deliverables such as an annual QAPI submission, an ODM-assigned annual performance improvement project (PIP) and oversight by an ODM-selected EQRO, there are many other responsibilities and processes outlined in Supplement 6 and 42CFR 438.330 that are not as clear as to whether these would necessarily be done by the Single PBM contractor, the MCOs or both. Could ODM provide additional insight as to whether the expectation is that for many of these responsibilities to be done by the Single PBM contractor or will the Single PBM contractor be primarily serving in a role supporting the MCOs and other ODM stakeholders and participating in their quality projects with regards to providing input on pharmacy aspects and ensuring they have access to pharmacy data as opposed to functioning as an independent quality organization?

Answer:   ODM will direct an integrated, coordinated Quality Improvement process to highlight and address specific public health and statewide needs through the coordinated efforts of the various managed care entities including the SPBM, therefore we anticipate both possible scenarios.

Date: 8/27/2020

Inquiry: 78116


Question:   Template C, Section 3.2 Pharmacy Benefit Management Projects Completed in the Last Three Years. Question: There appears to be a conflict in the answers provided by the State on August 20. In inquiry 78084, the State confirms that the bidder must provide information about contracts that have been terminated. However, in the answer to Inquiry 78075, the State indicates that this table must be filled out for all contracts both active and terminated in the last three years. Please confirm that bidders must fill out Table 5 in Section 3.2 for only terminated contracts.

Answer:   In response to Section 3.1, Offerors should provide narrative descriptions of all projects that are similar to the services requested in this RFP, in addition to Pharmacy Benefit Management experience in the Medicaid and healthcare space and a discussion of key trends affecting Pharmacy Benefit Management in the next three (3) to five (5) years and how this perspective will translate into benefits for Ohio. The projects cited can include active and terminated projects. In response to Section 3.2 – Table 5, completed projects are projects that have been implemented and have been moved into production. Offerors must include all Pharmacy Benefits Manager projects that have been implemented and are currently active. Additionally any project that had been in production and terminated within the last three (3) years must be included. Projects in the process of being implemented are not to be included in Table 5.

Date: 8/27/2020

Inquiry: 78120


Question:   SPBM RFP Base, Section 3.5 Proposal Submittal This section states that one (1) “originally signed” and eight (8) paper copies are required. Will the State accept electronic signatures in lieu of ‘wet’ signatures, given the present circumstances and associated restrictions / limitations in some states with regard to the COVID-19 pandemic?

Answer:   Yes, ODM will accept electronic signatures.

Date: 8/27/2020

Inquiry: 78094


Question:   Supplement 1 Scope of Work Section 2.9 Proposed Work Plan and Schedule - Page 22 Question: "The RFP states, ""A network diagram showing the planned start and end dates for all tasks and subtasks indicating the interrelationships of all tasks and subtasks and identifying the critical path. An electronic file of the detailed Project Schedule should be provided with the RFP response as well as a printed copy." Based on the question response, we understand the State wants a copy of the Network Diagram, however, we estimate that the printed version of the Network Diagram will be over 1100 pages, would it be acceptable to submit this requirement electronically opposed to printing?

Answer:   Yes, ODM would accept a printed and electronic Gantt Chart of summary-level tasks and a electronic only detailed network diagram of all tasks.

Date: 8/26/2020

Inquiry: 78159


Question:   In 4.1., Hardware and Software Assets The Contractor will support the State in defining and producing specific reports for both hardware and software assets. At a minimum this includes: 4.1.4. Software versions and then scans of versions against patches distributed and applied. Question: Does this apply to the Contractor’s assets or does this reference the states if used as part of the contract?

Answer:   This would include all hardware and software components the Offeror uses for the ODM solution, including components shared with other clients of the Offeror.

Date: 8/26/2020

Inquiry: 78146


Question:   Follow-up Question to Inquires #78115, 78989 and 77914 and Supplement One, Section 1 OVERVIEW OF SINGLE PHARMACY BENEFIT MANAGER MODULE (page 3) In Supplement One, Section One, the RFP states, “Currently, the combined PBMs process approximately 40,000 prior authorizations and fewer than 100 paper claims per month.”. Answers to questions state, “There were approximately 153,000 denied prior authorizations for managed care members during calendar year 2019.” Will the State please clarify if the numbers provided by ODM related to 480,000 MCO prior authorization and 153,000 denied prior authorizations? Please clarify if the 153,000 denials are included in the previously provided 480,000 MCO prior authorizations or in addition to the 480,000 MCO prior authorizations.

Answer:   The estimate of 480,000 MCO pharmacy prior authorizations includes the estimate of 153,000 pharmacy prior authorization denials.

Date: 8/26/2020

Inquiry: 78143


Question:   General Question - At what date does ODM expect that a contractor will need to be fully ready technically and operationally to fully support the FFS line of business? Worded another way, do we have to have full FFS capabilities complete and demonstrated to ODM at the time of the initial contract award?

Answer:   The Fee for Service members are expected to be transitioned in the second year of the contract. The Offeror is not required to have the capabilities to support the FFS pharmacy benefit at the initiation of the contract, but must demonstrate its ability to operate the FFS pharmacy program without impacting the managed care member program, including the implementation process and timeline, in their proposal.

Date: 8/26/2020

Inquiry: 78141


Question:   Supplement 1, 2. Project Organization and Staffing Requirements, 2.2 Key Roles, Table 1 - Required Key Roles - Is the expectation that both the AM and CAM work in the Lazarus Office?

Answer:   Yes, both the Account Manager and Clinical Account Manager are required to be onsite at ODM Columbus Office. Offerors must adhere to the COVID-19 guidance provided and updated by the State of Ohio in meeting these requirements (refer to https://coronavirus.ohio.gov/).

Date: 8/26/2020

Inquiry: 78127


Question:   RFP Base - 3.5 Proposal Submittal & 6.3 Attachment Three: Requirements for Proposal Question: Will the Department please confirm that the USB containing the digital copy of the Technical Proposal only contains one pdf (or as few pdf documents as possible) of the entire technical volume plus the native file for the work plan?

Answer:   Confirmed.

Date: 8/25/2020

Inquiry: 78157


Question:   The requirement OMES-320.010.030 requires the Contractor to provide ODM with results of the SSAE-18, SOC1, Type 1 and SOC2, Type 2 annually. Would ODM consider accepting the more comprehensive SOC1, Type 2 report in lieu of the annual SOC1, Type 1?

Answer:   Yes. ODM will accept SOC1, Type 2 reports.

Date: 8/25/2020

Inquiry: 78147


Question:   OMES-100.020.040 The Contractor’s solution must immediately reconcile errors upon identification, during the processing of any system transaction (e.g., online, batch), and immediately reprocess the transaction. Please identify an “error”? For example is it a configuration mistake or a bad eligibility file that was received?

Answer:   Processing errors would be failures to correctly adjudicate and pay claims, for example due to programming errors or incorrect reference files.

Date: 8/25/2020

Inquiry: 78145


Question:   OMES-100.050.110 The Contractor must provide post-implementation support for an ODM-approved period of time following service changes and system upgrades. Please define what is meant by “support.”

Answer:   The Offeror must include any ODM approved service change or system upgrade under Maintenance and Operations (refer to Supplement 1 - Section 7.1).

Date: 8/25/2020

Inquiry: 78144


Question:   Supplement 1, SPBM-160.100.040. Bidder’s Questions: 1. Please expand on what entails provider communications. 2. Where are the CMS releases published? 3. Could you expand on the boards and committees requirement? Would this be the board members of ODM or who? 4. What type of information or documentation would be included in a provider manual? 5. Can an architecture workflows be sufficient for claims processing/ billing manuals? 6. Where will the 1099 tax-related information be posted initially?

Answer:   This requirement is for the Offeror to support member and provider access to information sources through downloadable documents, searchable databases or links to public websites. Other requirements address if the Offeror is responsible for the content of these information sources.

Date: 8/25/2020

Inquiry: 78140


Question:   Supplement 3. If a Contractor believes that one of our systems would be fully used for the solution instead of an Ohio system described (for example, the InnovateOhio Platform), is the Contractor expected to outline any variances between our system and Ohios system? Or would we describe this as N/A?

Answer:   The Offeror must explain how their proposed solution meets the specific State IT Service Requirements if they will not be using a State of Ohio IT Services. A response of Not Applicable or N/A is not sufficient. An Offeror must document any proposed variance to a State IT Service Requirement in Supplement 3 - Appendix A. A proposed variance is a change to the requirement, not how that requirement will be met.

Date: 8/25/2020

Inquiry: 78138


Question:   General Question: Please confirm that the SPBM is expected to administer a single, unified pharmacy benefit across all 5 MCOs. a. If yes, will the SPBM unified pharmacy benefit align with the current Ohio Medicaid FFS program or will it be a separate benefit structure tailored to the MCOs? b. If no, while we understand that the PDL will be consistent for the Medicaid program, will each MCO have the ability to request that the SPBM implement and operate unique point-of-sale edits, UM criteria, etc. in support of their plan?

Answer:   The FFS program will have a separate benefit structure when implemented by the SPBM. The Offeror will administer a single unified pharmacy benefit for all MCO members, as directed by ODM.

Date: 8/25/2020

Inquiry: 78137


Question:   Template C, Section 3.3, Business Disputes (page 11) asks the Offeror to provide information for a wide variety of sanctions, actions, and litigation occurring variously over five, ten, or fifteen years. A multiline PBM, as a large business concern, may routinely encounter and handle such issues in the normal course of business. To more directly reflect the Offeror’s past performance behavior with respect to the requirements in the Ohio SPBM RFP, will ODM consider limiting the response for this requirement to actions directly involving public-sector programs (i.e., Medicaid, 340B, Medicare, and the like) and will ODM consider applying a uniform standard of five years for the information required?

Answer:   ODM will not limit the response.

Date: 8/25/2020

Inquiry: 78136


Question:   Template C, Section 3.2, (page 11), Pharmacy Benefit Management Projects Completed in the Last Three Years, asks Offerors to provide information for all service contracts/clients for the last three years this section also requests the same information for all subcontractors, associated companies, and consultants. A multiline PBM and subcontractors may have numerous such contracts spanning the past three years. Furthermore, such projects will have only limited relevance to the types of systems development, operations, and compliance requirements contemplated for the Ohio SPBM. Will ODM consider limiting the required response for this requirement to contracts involving public-sector programs (i.e., Medicaid, 340B, Medicare, and the like)?

Answer:   ODM will not limit the response.

Date: 8/25/2020

Inquiry: 78135


Question:   In response to Inquiry #77965. In the RFP Base, pages 39 & 40 and specifically state, "Each Proposal must be organized in an indexed binder with tabs labeled and ordered in the manner listed below. The Proposal must include the following tabbed sections:  Template A – Cover Letter, Executive Summary, and Subcontractor Letters  Template B –Terms and Conditions  Template C – Offeror Profile  Response to Supplement One  Response to Supplement Three  Response to Supplement Four  Response to Supplement Six  Response to Supplement Seven  Template D – Administrative Forms  Template E – Assumptions  Template F – Cost Proposal Workbook (Must be separately sealed)" Will the state please confirm that the offeror will not be considers noncompliant in the proposal response if Tabbed sections do not include Responses to Supplements Six and Seven?

Answer:   There is no requirement to include tabs for Supplements 6 and 7.

Date: 8/25/2020

Inquiry: 78134


Question:   Supp 1 - SOW 6.4, Training Question: Please provide an estimate of the number of ODM staff and stakeholders who will need to be trained on the Contractors systems, (eg., self service reporting system, call tracking system)

Answer:   Duplicate of 78128.

Date: 8/25/2020

Inquiry: 78133


Question:   • State Hearings – does the PBM representative have to attend in person or can they attend telephonically or via webex/skype/zoom. • State Hearings – Do the witnesses have to attend in person or can they attend telephonically or via webex/skype/zoom. Question Below is in regards to SLA 53, SLA 54, SLA 55, SLA 56 - How many of these various occurrences has ODM experienced in the last three years?

Answer:   The SPBM representative and witnesses may currently attend state hearings telephonically. The Ohio Department of Job and Family Services (ODFJS) Bureau of State Hearings (BSH) oversees state hearing procedures. The SPBM representative and any witnesses are expected to adhere to the state hearing administrative code rules outlined in OAC 5101:6-6, which may be amended from time to time by ODFJS. BSH ultimately controls the time, place, and manner of state hearings. ODM is unable to provide volumes of State Hearings PBM Representation requests, State Hearings PBM Witnesses requests, EQRO Cooperation requests or Program Integrity Information and Witness requests for managed care members.

Date: 8/25/2020

Inquiry: 78119


Question:   Supplement 1 Section 4.7 and Supplement 6 Section 3.2 Member Information Pages 13-14 In section 3.2, there are two instances of 3.2.c and 3.2.d. Should the second instances be 3.2.e and 3.2.f?

Answer:   There is a formatting error in Supplement 6 and the second occurrence of Section 3.2.c and Section 3.2.d should be Section 3.2.e and Section 3.2.f, respectively. There are no specific responses required for Supplements 6.

Date: 8/21/2020

Inquiry: 78093


Question:   Supplement One, Section 4.6 Table 10 – Clinical Quality Requirements Page 78 "SPBM-060.030.010 The requirement states that the Contractor must assist ODM with oversight of pharmacies for various pharmacy quality items, such as inappropriate auto-refills, use of 90-day fills. Where will the information about other pharmacies come from? "

Answer:   The Offeror must indicate how they will identify potential quality issues through the use of SPBM processed pharmacy claims.

Date: 8/21/2020

Inquiry: 78091


Question:   Supp 1 - SOW 6.4 Question: Please provide an estimate of the number of ODM staff and stakeholders who will need to be trained on the Contractors systems, (e.g., self service reporting system, call tracking system)

Answer:   The number of ODM staff and stakeholders needing to be trained by the Offeror will be determined by the proposed solution. It estimated to range from 25 to 100 individuals.

Date: 8/21/2020

Inquiry: 78128


Question:   Is Supplement Three necessary if Vendor is proposing a fully hosted solution?

Answer:   Supplement 3 is required.

Date: 8/21/2020

Inquiry: 78126


Question:   Supplement One, Section 5.9 Reporting and Analytics. SPBM-180.140.070. Page 131. The Contractor must include in the Quarterly Clinical Report recommendations for drugs and / or drug classes to be added to the automated pharmacy prior authorization tool, and pre-analysis and post-analysis data for retro-DUR interventions and ProDUR recommendations. Is the vendor required to implement and manage a retro-DUR solution requiring outreach and response tracking, OR is the state only asking the vendor to make recommendations and measure results of the state’s interventions?

Answer:   ODM will be implementing and managing the retro-DUR process with the assistance of our Pharmacy Benefits Administrator. The SPBM will be an active participant in the retro-DUR process, including providing the pharmacy claims data and DUR recommendations.

Date: 8/21/2020

Inquiry: 78117


Question:   Supplement One: SPBM-110.110.040 The Contractor’s solution must integrate with the Ohio Administrative Knowledge System (OAKS) for the purposes of finance management. Question: Please define financial management will the information be used in the preparation of financial statements or only for analysis?

Answer:   Financial management is the process of the Offeror submitting the data for the reimbursement for pharmacy claims payments and invoices for administrative contractual fees and receiving data for disbursement of state funds and administrative fee payments.

Date: 8/21/2020

Inquiry: 78113


Question:   Supplement 7- Managed Care Rules, Section 11.(B)(3)(c). Question: The requirement says, "For denial of payment for a non-covered service, the MCO or SPBM shall give notice simultaneously with the MCO or SPBMs determination to deny the claim, in whole or part, for a service not covered by medicaid, including a service determined through the MCO or SPBMs prior." Please confirm that claim means point-of-sale transaction and not prior authorization transaction. Will the SPBM be required to send NOAs for claims that are denied at the pharmacy/point-of-sale for not a covered benefit?

Answer:   Claim means a submission that moves past the point-of-sale system and is sent to the SPBM for adjudication and/or prior authorization review. The SPBM will not be required to send NOAs for claims denied at the pharmacy/point-of-sale for a non-covered benefit.

Date: 8/21/2020

Inquiry: 78106


Question:   Question regarding SPBM-110.110.040: What type of integration/s does OAKS support? Can any additional details be provided around OAKS capabilities in order to address and respond to Contractors capabilities to integrate with it?

Answer:   The OAKS integration currently uses proprietary flat file data exchanges (for example, the INF02 (provider payment) format is available at: https://procure.ohio.gov/ProcOppForm/0A1082_Supplement%2017%20-%20INF02%20Draw%20Request%20File%20Layout.pdf). ODM will provide the selected Offeror integration file formats during the implementation phase, as these are subject to change.

Date: 8/21/2020

Inquiry: 78103


Question:   Follow-up to Question #77989. Supplement One, SPBM-020.040.130 Question: The Contractor must notify the recipient when PA is denied. Will ODM provide the number of denied PAs on a monthly, quarterly or annual basis, please? Answer: There were approximately 153,000 denied prior authorizations for managed care members during calendar year 2019. Will the State pleas clarify how many of the denied prior authorizations were FFS related?

Answer:   ODM is unable to provide volumes of denied prior authorization for fee for service members.

Date: 8/21/2020

Inquiry: 78115


Question:   Supplement 7, Managed Care Rules, 11(B)(3)(c). The requirement says, "For denial of payment for a non-covered service, the MCO or SPBM shall give notice simultaneously with the MCO or SPBMs determination to deny the claim, in whole or part, for a service not covered by medicaid, including a service determined through the MCO or SPBMs prior." Please confirm that claim means point-of-sale transaction and not prior authorization transaction. Will the SPBM be required to send NOAs for claims that are denied at the pharmacy/point-of-sale for not a covered benefit?

Answer:   Duplicate of Inquiry 78106.

Date: 8/21/2020

Inquiry: 78114


Question:   RFP Format: Can we place the word documents in our own format?

Answer:   No.

Date: 8/21/2020

Inquiry: 78108


Question:   Supplement 7- Managed Care Rules, Section 11.(B)(3)(c). Question: The requirement says, "For denial of payment for a non-covered service, the MCO or SPBM shall give notice simultaneously with the MCO or SPBMs determination to deny the claim, in whole or part, for a service not covered by medicaid, including a service determined through the MCO or SPBMs prior." Please confirm that claim means point-of-sale transaction and not prior authorization transaction. Will the SPBM be required to send NOAs for claims that are denied at the pharmacy/point-of-sale for not a covered benefit?

Answer:   Duplicate of Inquiry 78106.

Date: 8/21/2020

Inquiry: 78107


Question:   SPBM-030.030.010 The Contractor must work with ODM to develop groupings and payment cycles for all payables. The Contractor’s solution must identify and process payable items and pay on ODM-defined schedules. The Contractor’s solution must have functionality to pause or stop a payment cycle which must be granted to ODM-authorized users. Q. Does this require the capability to stop payments to a particular pharmacy or payee or holding the whole financial cycle?

Answer:   The Offeror must be able to pause or stop payments for an individual pharmacy, payee groupings, as defined by ODM, and the entire payment cycle.

Date: 8/21/2020

Inquiry: 78100


Question:   SPBM-030.020.050 The Contractor’s solution must have functionality to require manual approvals of receivables by ODM-authorized staff, as specified by ODM. Q. What type of approval? For what receivables?

Answer:   The Offeror must propose the process for manually approving receivables. All receivables may be subject to manual approval.

Date: 8/21/2020

Inquiry: 78099


Question:   4SPBM-030.020.030 The Contractor’s solution must have functionality to establish repayment terms for receivables (e.g., net 30, full offsets, limited offsets (amount and percentage), monthly amounts, deferred). The Contractor must work with OME to establish repayment terms and rules for application to receivable accounts. Q. What type of receivables does the requirement refers to? From pharmacies? Other payers? Please explain.

Answer:   Receivables include pharmacy negative balances. It would also include MCO negative balances associated with services, such as quality improvement initiatives, that would be contracted by the MCO and paid to the participating pharmacies, and member negative balances for any patient liability.

Date: 8/21/2020

Inquiry: 78098


Question:   SPBM-030.020.020 The Contractor’s solution must have functionality to accept, calculate, process, and store amounts owed by enrolled individuals (e.g., member copayments), based on ODM-defined business rules. Q. Does this refers to patient responsibility (ex. Copay) not paid at point of sale? For example, related to claims rework or adjustments? If other cases, please explain.

Answer:   Requirement SPBM-030.020.020 refers to all patient liability. Copayments not paid at the point of sale are the most likely source of patient liability, but there may be other sources of patient liability in the future.

Date: 8/21/2020

Inquiry: 78097


Question:   2SPBM-030.020.010 The Contractor’s solution must capture and maintain accounts receivable for pharmacy services within the OMES. The Contractor must work with OME to establish the rules and processes for receivables accounts including, but not limited to, data elements to collect and maintain, terms and conditions, offsets and adjustments to receivable balances. Q. Does these receivables refer to negative balances from pharmacies? If other payers, which ones?

Answer:   Receivables include pharmacy negative balances. It would also include MCO negative balances associated with services, such as quality improvement initiatives, that would be contracted by the MCO and paid to the participating pharmacies, and member negative balances for any patient liability.

Date: 8/21/2020

Inquiry: 78096


Question:   SPBM-030.010.020 The Contractor’s solution must capture, maintain, and process unique program and service-related payments. Q. What type of programs and services does this section refers to? Are they payable to pharmacies?

Answer:   SPBM-030.010.020 is applicable to all payments and all payments will be issued to pharmacies.

Date: 8/21/2020

Inquiry: 78095


Question:   Supplement 1 Section 4.7 and Supplement 6 Sections 4.5 and 4.6 Table 11 – PAHP Functions and Operation Requirements Page 80 SPBM-070.010.020 Indicates that The Contractor must notify members who regularly use a terminated provider in accordance with the requirements in Supplement 6, Section 4.6. However, 4.6 in supplement 6 relates to Timely Access. Section 4.5.b appears to relate to member notification. Should the response to SPBM-070.010.020 be for 4.6 Timely Access or for or 4.5.b Notice to Members. Additionally, should 4.6 Timely Access be included in SPBM-070.010.010

Answer:   The reference to Supplement 6, Section 4.6 in Requirement SPBM-070.010.020 is incorrect. The correct reference is Supplement 6, Section 4.5.b. Supplement 6, Section 4.6 is not relevant to Requirement SPBM-070.010.020.

Date: 8/21/2020

Inquiry: 78092


Question:   Supplement One, Section 4.7 Table 11 – PAHP Functions and Operation Requirements Page 82 SPBM-070.040.070 The Contractor must have a process to notify ODM within one business day when a claim is denied due to the use of a provider ID that is not supported (i.e., not an NPI) and the provider requests reconsideration of the denied claim. Will ODM please provide examples other than NPI?

Answer:   Duplicate of Inquiry 78089.

Date: 8/21/2020

Inquiry: 78090


Question:   Supplement One, Section 4.7 Table 11 – PAHP Functions and Operation Requirements Page 82 SPBM-070.040.070 The Contractor must have a process to notify ODM within one business day when a claim is denied due to the use of a provider ID that is not supported (i.e., not an NPI) and the provider requests reconsideration of the denied claim. Will ODM please provide examples other than NPI?

Answer:   Legacy provider identifier issued by Medicare, Medicaid or commercial health plans.

Date: 8/21/2020

Inquiry: 78089


Question:   Question regarding SPBM-010.020.020, specifically "...including but not limited to:...Contractors TPL resources..." Is it the expectation of ODM that the Contractor will maintain a relationship with an external, third party, TPL vendor in order to supplement ODMs TPL data?

Answer:   The Offeror must indicate how they will obtain "maximum cost avoidance and reimbursement for beneficiaries covered by third parties", which may include relationships with ODM approved external entities.

Date: 8/21/2020

Inquiry: 78088


Question:   SPBM-070.000.030: Will ODM will be providing the medical/surgical benefit to the contractor to assess parity or will ODM be doing that comparison?

Answer:   ODM will complete the parity analysis.

Date: 8/21/2020

Inquiry: 78079


Question:   SPBM-030.030.070: Can you provide clarification on what is meant by "user-configured limits are reached (e.g., maximum amounts by funding source)"? Or provide an example of when this functionality would be required?

Answer:   Example: A maximum amount of payment per weekly payment cycle or cumulative payments (quarterly or annual), as defined by ODM. Payments above the threshold would be held and issued in a future payment cycle.

Date: 8/20/2020

Inquiry: 78085


Question:   Please confirm that the disclosure requested in Question 3 of Template C requests information about pharmacy services contracts that have been terminated.

Answer:   Confirmed.

Date: 8/20/2020

Inquiry: 78084


Question:   1. Please advise if ODM will accept an MBE supplier who is in the process of getting certified by the state? 2. Would you accept an MBE supplier who is not certified by the State of Ohio but instead as the following certifications: City of Philadelphia, CPUC - California Public Utilities Commission, NMSDC (National Minority Supplier Development Council), Self Certified, Southern California MSDC?

Answer:   In response to question 1, the Proposal must provide the following: the MBE Offeror(s) name, the Ohio DAS-MBE certification letter, a stated specific percentage of the cost of the work that it will set-aside for Ohio MBE-certified subcontractors only, and a letter form the Ohio MBE-certified subcontractors, on company letterhead agreeing to the performance of work requested by the prime Offeror. In response to question 2, no, the subcontractor must be Ohio DAS-MBE certified.

Date: 8/20/2020

Inquiry: 78083


Question:   There are two PGs that are currently asking for the same thing. Please advise how we should be answering: SLA 17 Claims Quality Assurance Service Level Description:  Contractor’s system must receive, adjudicate and correctly price 100% of pharmacy claims, including claims for multi-ingredient compounded prescriptions whether submitted electronically or on paper. Compliance and Calculation:  100% of all claims in a weekly payment cycle must be adjudicated and correctly priced.  (Number of claims adjudicated and correctly priced per week) / (Total number of claims adjudicated and priced per week) X 100. $1,000 for each 0.1% below 100% for a weekly payment cycle. SLA 34 Accurate Processing and Pricing of Pharmacy Claims Description:  The Contractor must adjudicate, price, and pay submitted pharmacy claims consistent with state business rules and federal regulations per state-defined payment schedules. Compliance and Calculation:  99.5% of all claims in a weekly payment cycle must be paid with a 100% accuracy rate.  (Number of claims paid accurately in a week) / (Total number of claims paid in a week) X 100. $5,000 for each 0.1% below each weekly payment cycle the service level is unmet.

Answer:   SLA 17 measures claims adjudication of pharmacy claims and SLA 34 measures the payment of pharmacy claims. While closely related, claims payment involves additional process steps and the disbursement of funds to the provider.

Date: 8/20/2020

Inquiry: 78082


Question:   TEMPLATE B: TERMS AND CONDITIONS regarding SLA 56 for Program Integrity Information and Witness Requests. 1. Can you provide an approximate time frame that is generally applied to these requests, such as 30 days? 2. Can you also describe the general types of requests that fall under this SLA such as request for information, request for investigation materials and evidence, witness statements, or other request types?

Answer:   Refer to Supplement 6 - Sections 5.12 and 5.13.

Date: 8/20/2020

Inquiry: 78081


Question:   SPBM-170.100.010: Can you elaborate or provide information on the term "accounting structure" as it relates to this requirement?

Answer:   Accounting structure refers to how the Offeror organizes their financial systems. Also referred to as a Chart of Accounts.

Date: 8/20/2020

Inquiry: 78080


Question:   Supplement One, Table 15 Question: Regarding OMES-130.000.070 in Data Management Requirements, please describe the use cases or business conditions that would require the SPBM Contractor to utilize the ODM Master Data Management services. We also would like to know what type of interfaces (real-time vs. batch) are available to send raw data and receive mastered data.

Answer:   The OMES system offers both real time web services using a publish/subscribe model and batch processing through SFTP. The MDM component is most easily accessed through the web service. In addition, there is an EDI option available for near real-time and batch transmissions.

Date: 8/20/2020

Inquiry: 78076


Question:   Template C, Section Pharmacy Benefit Management Projects Completed in the Last Three Years. The RFP directs bidders to provide this information for all service contracts/clients in the Pharmacy Benefit Management space during the last three (3) years. Please clarify, should bidders provide information on contracts that have ended during the last three years and are no longer in force? Or should bidders provide the requested information for all contracts, both active and terminated, in the last three years.

Answer:   Offerors should provide the requested information for all contracts, both active and/or terminated, in the past three years.

Date: 8/20/2020

Inquiry: 78075


Question:   In reference to Section 1.4 RFP Process (RFP Base, page 7, 8) : The Offeror’s submitted proposal must include a competitively selected Ohio-certified MBE subcontractor Offeror, or Offerors, that will conduct, at a minimum, 15 percent (15%) of the cost of the Contract per State fiscal year. Can a subcontractor/delegated Vendor to the Offeror meet the 15% MBE requirement on behalf of the Offeror?

Answer:   A subcontractor can meet the 15% Ohio-certified MBE requirement on behalf of the Offeror. The Offeror is required to select the Ohio certified Minority Business Enterprise subcontractor(s) through a competitive process. The competitive process can be a request for quote through email, or some other reasonable process, to be determined by the Offeror. The details of the procurement process are not expected to be provided to ODM unless specifically requested.

Date: 8/20/2020

Inquiry: 78071


Question:   Regarding SPBM-010.090.060, can you advise what the "maximum processing times" referenced are?

Answer:   Refer to Template B - Terms and Conditions: Real-Time Performance Service Level (page 19).

Date: 8/20/2020

Inquiry: 78065


Question:   SPBM Supplement 1 - Scope Work Claim Processing Requirement ID: SSPBM-010.100.020 Page 45 SPBM-010.100.020 The Contractor must provide trading partner testing and trouble resolution assistance with all trading partners at no additional cost to the trading partner or ODM. Question: Could you please define "trading partner"?

Answer:   A trading partner is any entity with which the SPBM exchanges data electronically on behalf of ODM. These entities include, but are not specifically limited to, providers, their vendors, and facilitating data network providers (e.g., clearinghouses, switches, hubs).

Date: 8/20/2020

Inquiry: 78064


Question:   Supplement 1, Claim Review, SPBM-050.030.010. Can you clarify the expectations for an "onsite review"?

Answer:   Onsite claims reviews would be utilized only when being physically present at the dispensing pharmacy is required to conduct the review. The selected Offeror must be actively involved in determining when onsite reviews are required.

Date: 8/20/2020

Inquiry: 78063


Question:   Supplement 1, Claim Review SPBM-050.000.060. Can you clarify what is meant by "using technology currently supported to facilitate document storage and retrieval on an as needed basis"?

Answer:   This requirement is speaking to the need for reporting data being provided in the file format of applications used by the State, for example an Excel format for file extracts, and made available from file storage platforms accessible to the State, such as a SFTP server.

Date: 8/20/2020

Inquiry: 78062


Question:   Supplement 1 - Finance Management Section Please confirm if the "receivables" mentioned in a number of requirements in this section refer to member, pharmacy, or client receivables.

Answer:   The majority of receivables will result when a participating pharmacy has been overpaid and funds must be recouped. A receivable may be created for an MCO for any financial liability associated with services, such as quality improvement initiatives, that would be contracted by the MCO and paid to the participating pharmacies. Receivables for members would be created for any patient liability. There is no expectation that client (ODM) receivables would be created.

Date: 8/20/2020

Inquiry: 78046


Question:   Supplement Six, 5.9(c)iii, v, vi., vii. Question: Please confirm that the responsibility for investigating prescribers does not include desk or onsite audits.

Answer:   The Offeror is expected to make appropriate referrals when it identifies potentially fraudulent activities by a prescriber. It is not expected that the Offeror would conduct desk reviews or audit of prescribers.

Date: 8/20/2020

Inquiry: 78042


Question:   Is there a requirement to formally communicate our intent to BID, or will our submission of the 2019 RFI suffice? There is a Cover Letter in Template A, and that will be submitted with the final package on 9/4, but is an intent to bid due prior to the due date to the due date?

Answer:   Offerors are not required to submit an intent to bid or to have responded to the Single Pharmacy Benefit Manager RFI in order to submit a proposal to this RFP.

Date: 8/18/2020

Inquiry: 78052


Question:   Scope of Work: 4.3 Finance management: SPBM-030.030.050. The Contractor’s solution must capture, maintain, and report on unsettled disbursements (e.g., uncleared EFTs, returned warrants). The Contractor must research reasons for unsettled disbursements and correct where possible, and any disbursements that cannot be completed must be returned to ODM. The Contractor must work with OME to establish the processes to address unsettled disbursements including, but not limited to, voiding and reissuing disbursements. Question: How many rejected provider payment Efts’ are received on a monthly basis?

Answer:   ODM is unable to provide volumes of uncleared EFT payments for managed care members. Offerors are encouraged to investigate industry standards to model these volumes.

Date: 8/18/2020

Inquiry: 78050


Question:   Template B, Section 4.2, Ongoing Performance Standards, SLA 3. Please define or provide examples of what is considered a "Helpdesk Incident"?

Answer:   A “Critical Helpdesk Incident” is a complete failure or significant degradation of service of a module or support module that affects all users of the module or support module, and no workaround exists. A “High Helpdesk Incident” affects the critical functionality, but there is a temporary workaround however it is difficult to implement. A “Medium Helpdesk Incident” is a degradation of a service, without a failure, and with a State-approved workaround. A “Low Helpdesk Incident” is a non-substantial Incident or defect that does not present an interruption in service degradation of a service.

Date: 8/18/2020

Inquiry: 78049


Question:   Supplement 1 - SPBM 030.030.060 Can you specify the exact terms of the pharmacy payment cycle mentioned here?

Answer:   This requirement addresses functionality for an exception process to allow ODM-authorized uses to manually initiate or hold a payment.

Date: 8/18/2020

Inquiry: 78045


Question:   Supplement 1 - 2. SPBM 030.030.050 Please specify the direction of the disbursements. Does this refer to PBM > Pharmacy disbursements?

Answer:   The SPBM will be issuing payments directly to the pharmacies. This requirement addresses control processes and resolution when payments are not successfully completed.

Date: 8/18/2020

Inquiry: 78044


Question:   Supplement One, Tables 5-27 Question: Please confirm that Tables 5 through 27 contain a complete list of requirements, as several of the numbered requirements skip in sequence. For example, in Table 26, OEMS-310.010.030 skips to OEMS-310.010.060. Should there be 310.010.040 and 310.010.050?

Answer:   Requirement IDs are not a sequential list and are for label reference only. All requirements are included in the RFP.

Date: 8/18/2020

Inquiry: 78043


Question:   Supplement Six, Section 5, Program Integrity Question: How many referrals of pharmacy FWA were made to ODM in the previous two years?

Answer:   ODM is unable to provide volumes of pharmacy FWA referrals for managed care members. Offerors are encouraged to investigate industry standards to model these volumes.

Date: 8/18/2020

Inquiry: 78041


Question:   Supplement Six, Section 5, Program Integrity Question: How many allegations of suspected pharmacy FWA were received in the previous two years by year?

Answer:   ODM is unable to provide volumes of suspected pharmacy FWA allegations for managed care members. Offerors are encouraged to investigate industry standards to model these volumes.

Date: 8/18/2020

Inquiry: 78040


Question:   Supplement Six, Section 5, Program Integrity Question: Please provide the average volume of claims over $10,000 per day.

Answer:   ODM is unable to provide volumes of claims over $10,000 per day for the managed care members. Offerors are encouraged to investigate industry standards to model these volumes.

Date: 8/18/2020

Inquiry: 78039


Question:   Supplement One, SPBM-050.010.120 Question: Please provide the volume of audits conducted in-store and desk in the previous two years.

Answer:   ODM is unable to provide volumes of audits conducted in-store and desk. Offerors are encouraged to investigate industry standards to model these volumes.

Date: 8/18/2020

Inquiry: 78038


Question:   In reference to Section 2.3 Mandatory Qualification #3 – MBE (Template C – Offeror Profile, page 8) : The Mandatory Qualification states that the Offeror must provide a detailed plan which demonstrates that a minimum of 15% of the cost of the work each state fiscal year under the resulting Contract will be subcontracted through one (or more) Ohio Certified Minority Business Enterprise (MBE) Offerors. Does "15% of the cost" refer to the Offeror’s administrative cost or 15% of the total budget?

Answer:   The 15% MBE subcontracting requirement refers to the total budget, per fiscal year. The Offeror's total budget does not include pass-through payments to the pharmacies.

Date: 8/18/2020

Inquiry: 78029


Question:   In reference to Section 6.1 Attachment One: Evaluation Criteria (RFP Base, page 28, 29) : The Minimum Mandatory Requirements state that Offerors must adhere to and provide relevant information needed, to meet each mandatory requirement identified below. Any Proposal failing to do so will be disqualified from evaluation… If the Offeror’s Proposal meets the mandatory requirements, then the Offeror’s Proposal may proceed to the technical evaluation phase. Please clarify “may proceed”. Does the State use its own discretion to determine whether the Offeror’s Proposal meets the mandatory (pass/fail) requirements?

Answer:   Under this phase of the evaluation, the State will use its discretion to the extent that the State will review the Proposals to determine if the submission responses related to the mandatory requirements meet the mandatory requirements identified in this Section 6.1. The statement “may proceed” means those Proposals that meet the Minimum Mandatory Requirements can be permitted to move on to the next phase of evaluation, which is the Technical Evaluation Phase.

Date: 8/18/2020

Inquiry: 78032


Question:   RFP Base, Section 6.3, Proposal Requirements and Format, page 41 states "Offerors must identify and describe any exceptions to the RFP requirements using the RFP requirement number and languge." Is the expectation of ODM that offerors will draft and submit with the proposal an Interval Deliverable Agreement (IDA) for any exceptions to the RFP requirements based on the IDA process described in RFP Base, Section 6.2?

Answer:   No, Interval Deliverable Agreements are not expected to be provided with the proposal.

Date: 8/18/2020

Inquiry: 78027


Question:   SPBM-040.000.190 Can you define capture rate?

Answer:   95% percent of the calls are connected to a customer service representative. Could also be measured as 5% or less call abandonment rate.

Date: 8/18/2020

Inquiry: 78013


Question:   Relevant RFP Part - Document Name: Supplement One: Scope of Work Relevant RFP Part (Section/Sub-Section): 4.2 Heading for Provision being Questioned: Utilization Management RFP Page #: 55 Question: SPBM-020.050.020 The requirement is for the contractor to have the capability to produce an extract file of procedure code drug pricing to be shared and used by other stakeholders processing claims. Please provide information about at what level this extract file will need to be shared. Does this file require pricing detail at the NDC level crosswalked back to the assigned HCPCS code? What price types must be included in the file to support processing claims by other stakeholders? What is the estimated volume of claims that other stakeholders will adjudicate using this data? Please note: to obtain a data source approved licensed use agreement to share pricing and data elements, vendors must provide an estimated volume of claims that will be processed using this requested data.

Answer:   The Offeror must attest to being capable to meet the requirements described in SPBM-020.050.020. Please refer to SPBM-020.050.010 for additional requirements of the crosswalk. ODM will negotiate alongside the selected Offeror during the implementation phase to secure licensing for data use from the source of the data. ODM will work with the selected Offeror to identify claims volume.

Date: 8/18/2020

Inquiry: 77973


Question:   The Contractor must notify the recipient when PA is denied. Will ODM provide the number of denied PAs on a monthly, quarterly or annual basis, please?

Answer:   Duplicate of 77914

Date: 8/18/2020

Inquiry: 77915


Question:   1. In reference to Section 1.4 Security and Data Protection (Supplement 4 - State Information Security and Privacy Requirements, State Data Handling Requirements, page 6): The Security and Data Protection requirements state that the solution must provide the State’s systems administrators with 24x7 visibility into the services through a real-time web-based “dashboard” capability that enables them to monitor, in real or near real time, the services’ performance against the established service level agreements and promised operational parameters. Do we have established SLAs or promised operational parameters defined for use to know what the requirements are? 2. In reference to Section 1.8 State Network Access (VPN) (Supplement 4 - State Information Security and Privacy Requirements, State Data Handling Requirements, page 11): The State Network Access (VPN) requirements state that any remote access to State systems and networks, Contractor or otherwise, must employ secure data transmission protocols, including transport layer security (TLS) and public key authentication, signing and/or encryption. Any remote access solution must use Secure Multipurpose Internet Mail Extensions (S/MIME) to provide encryption and non-repudiation services through digital certificates and the provided public key infrastructure (PKI). Please clarify the requirement. Is the Offeror to assume that they are acting as a managed security provider? S/MIME is a scheme for sending secure email, not providing remote access. 3. In reference to Section 3.1 General (Supplement 4 - State Information Security and Privacy Requirements, State Data Handling Requirements, page 17): The requirements state, “if, over the course of the Contract a security or privacy issue arises, whether detected by the State, a State auditor, or the Contractor, that was not existing within an in-scope environment or service prior to the commencement of any contracted service associated with this Contract, the Contractor must…” Please clarify what is meant by a “Security or Privacy Issue” as there are some very tight timelines in these requirements. 4. In reference to Section 4.3 Boundary Defenses and Section 4.4 Audit Log Reviews (Supplement 4 - State Information Security and Privacy Requirements, State Data Handling Requirements, page 22): The requirements state that the Contractor must work with the State to support the denial of communications to/from known malicious IP addresses, support the State’s monitoring and management of devices remotely logging into the internal network, as well as, meet all requirements regarding Audit Log Reviews. Please provide clarity and context. Are we to help the State create reports, audit logs, etc. and if so, whose hardware is the State focusing on?

Answer:   1. Please refer to Template B - Terms and Conditions, Section 4. 2. Offerors must explain how they will securely access State networks, including all applicable technologies and standards. 3. Any attempted or successful unauthorized access, use, disclosure, modification, or destruction of information or interference with system operations in an information system (45 CFR 164.304), or any acquisition, access, use, or disclosure of protected health information in a manner not permitted under the HIPAA Privacy Rule (45 CFR Part 164 Subpart E) which compromises the security or privacy of the protected health information. 4. The Offeror must propose how they will monitor for and prevent intrusion into their proposed solution, thus preventing intrusion into connected State networks. OMES is modular and it is intended the Offeror respond only in the context of their proposed solution. There are no requirements for the Offeror to log environments outside of the Module. The Offeror will be required to work with the State to address evolving threats throughout maintenance and operations.

Date: 8/18/2020

Inquiry: 77958


Question:   In regards to Section 6.1 of the RFP Base, in the second minimum mandatory requirement related to bidder experience, is “similar size and scope” intended to mean a minimum requirement that the bidder have three separate clients with similar size and scope to the Ohio Medicare population of around 2.9 million members each for a total of around 9 million members, or at least three clients which in aggregate have at least 2.9 million members?

Answer:   The purpose of this requirement is to ensure that the solution offered by the potential vendor will be able to meet the needs of ODM. It is incumbent on the Offeror to demonstrate its capacity and capability to handle the complexities and volume that are anticipated for Ohio's PBM. Offerors can meet the size and scope requirement in a number of ways. Possible examples include experience serving comparable populations of covered lives or pharmacy claim volumes as in the Ohio Medicaid managed care program. The examples could also include prior or current PBM projects that are smaller than the Ohio Medicaid Managed Care program but are nevertheless sufficiently significant in size and scope to demonstrate the capability of serving the needs of Ohio. Offerors should provide examples of experience from at least three projects, but Offerors can also submit more than three examples or examples of significant operations plus the ability to scale up operations. When reviewing submissions in response to this requirement, ODM will focus on whether the Offeror's proposed solution has the capacity and capability of performing the required job.

Date: 8/17/2020

Inquiry: 77982


Question:   Regarding Minimum Mandatory Requirement #2 The Offeror must demonstrate experience within the last three (3) years as the prime PBM Contractor for at least three (3) federal, state, local government or private healthcare entities where the solution of similar size and scope is currently being or has been implemented. Could you please confirm the following: An Offeror holding the primary contract with the Federal, State, or local government entities for a period of at least 3 years of similar size and scope, and who subcontracted PBM services to a PBM vendor, would meet the “Prime PBM contractor relationship” and therefore pass this requirement.

Answer:   The purpose of this requirement is to ensure that the solution offered by the potential vendor will be able to meet the needs of ODM. It is incumbent on the Offeror to demonstrate its capacity and capability to handle the complexities and volume that are anticipated for Ohio's PBM. Offerors can meet the size and scope requirement in a number of ways. Possible examples include experience serving comparable populations of covered lives or pharmacy claim volumes as in the Ohio Medicaid managed care program. The examples could also include prior or current PBM projects that are smaller than the Ohio Medicaid Managed Care program but are nevertheless sufficiently significant in size and scope to demonstrate the capability of serving the needs of Ohio. Offerors should provide examples of experience from at least three projects, but Offerors can also submit more than three examples or examples of significant operations plus the ability to scale up operations. When reviewing submissions in response to this requirement, ODM will focus on whether the Offeror's proposed solution has the capacity and capability of performing the required job.

Date: 8/17/2020

Inquiry: 77959


Question:   In light of the impacts of the pandemic on the application process and its timing, will ODM accept a bidder’s obtaining its TPA license by the time work on this contract begins as meeting the minimum mandatory requirements of the RFP.?

Answer:   Offeror must be a third-party administrator as defined in ORC 5167.01 and meet the requirements to be an Administrator in accordance with Chapter 3959 of the Revised Code at proposal submission. The online application can be found on the Ohio Department of Insurance website.

Date: 8/17/2020

Inquiry: 77916


Question:   1. In reference to Section 1.6 Anticipated Procurement Timetable (RFP Base page 10) and Section 3.5 Proposal Submittal (RFP Base page 15) : There are conflicting statements regarding the due date in the submission requirements. Please confirm that the final due date is September 4th, 2020 at 4:00 p.m. (Columbus, Ohio local time). 2. In reference to Section 1.4 RFP Process (RFP Base page 8) : The MBE requirement states that we must have a competitive selection of a qualified MBE. If we are currently working with an approved MBE that was previously selected through a competitive process can we use and count that vendor? 3. In reference to Section 1.4 RFP Process (RFP Base page 8) : Does ODM expect a competitive bidding process for MBEs? If so, due to the short turnaround time, will the state accept submissions after the submission date? 4. In reference to Section 1.4 RFP Process (RFP Base page 8) : How many years of experience is the MBE required to have? 5. In reference to Section 1.4 RFP Process (RFP Base Page 8) : Can the vendor be in the process of becoming a MBE or apply now that the RFP has been released? 6. In reference to Section 1.4 RFP Process (RFP Base page 8) : Can ODM share the due diligence it will conduct on the MBE? 7. In reference to Section 6.1 Attachment One: Evaluation Criteria (RFP Base page 29) : Does ODM expect a legal firewall/policy document to be submitted with the RFP response which articulates its plan for mitigating potential conflicts as noted? 8. In reference to Section 6.1 Attachment One: Evaluation Criteria (RFP Base page 29) : How will ODM determine if the Offeror’s experience as the prime PBM Contractor for at least three (3) federal, state, local government, or private healthcare entities meets the size and scope requirement? 9. In reference to Section 6.1 Attachment One: Evaluation Criteria (RFP Base page 29) : Is the requirement to be a third-party administrator as defined in ORC 5167.01 and meet the requirements to be an Administrator in accordance with Chapter 3959 of the Revised Code a condition that must be satisfied in order to submit a proposal to the RFP? 10. In reference to Section 6.1 Attachment One: Evaluation Criteria (RFP Base page 29) : If the Offeror does not currently meet the requirements to be a third-party administrator as defined in ORC 5167.01 and meet the requirements to be an Administrator in accordance with Chapter 3959 of the Revised Code, will ODM consider the proposal as long as the Offeror meets the requirements at the time of the contract award? 11. In reference to Section 6.1 Attachment One: Evaluation Criteria (RFP Base page 29) : The Minimum Mandatory Requirements state that the Offeror must be a third-party administrator as defined in ORC 5167.01 and meet the requirements to be an Administrator in accordance with Chapter 3959 of the Revised Code. Must licensure be complete at the time of submission, or will ODM allow Offerors to submit responses so long as the Offeror is licensed before go-live? 12. In reference to Section 6.2 Attachment Two: Special Provisions & Interval Deliverable Agreement (RFP Base page 35) : The Location of Data requirements state that the Contractor must perform all work on the Project and keep all state data within the United States, and ODM may reject any Proposal that proposes to do any work or make State data available outside the United States. What process will ODM take to verify this has occurred? 13. In reference to Section 6.3 Attachment Three: Requirements for Proposal (RFP Base page 42) : The RFP notes that the "Subcontractor Letter" must include the elements noted under the "Cover Letter" section of the RFP. Is the expectation that the Subcontractor will also include an "Executive Summary" and "Table of Content" in their "Cover Letter"?

Answer:   1. Proposals must be received no later than September 4th at 4 p.m. 2. The Offeror is required to select the MBE(s) through a competitive process, which can be a request for quote through email, or some other reasonable process, to be determined by the Offeror. The details of the procurement process are not expected to be provided to ODM unless specifically requested. 3. The MBE subcontractor(s) must be selected prior to proposal submission. 4. There are no requirements for years of experience for MBEs in this RFP. All subcontractors are subject to the Terms and Conditions of the Contract. 5. The proposal must provide the MBE Offeror(s) name and DAS-MBE certification letter. 6. This process can be found in ARTICLE IX. CONTRACTOR CERTIFICATION OF COMPLIANCE WITH SPECIAL CONDITIONS, Section 8 of the sample contract provided in the RFP. 7. Yes, a Plan of Action for an actual, potential, or potentially apparent conflict of interest must be submitted with the response to the RFP. The Plan of Action must detail the actual, potential, or potentially apparent conflict or issue and detail the processes and procedures that the Offeror will undertake to ensure independence, transparency, and objectivity. ODM has sole discretion to accept or reject the sufficiency of a proposed Plan of Action and, during the process of evaluation, ODM may seek clarification. If the Plan of Action is rejected, ODM will apprise the Offeror and provide the Offeror the opportunity to retract its RFP response before announcement of the award. 8. The purpose of this requirement is to ensure that the solution offered by the potential vendor will be able to meet the needs of ODM. It is incumbent on the Offeror to demonstrate its capacity and capability to handle the complexities and volume that are anticipated for Ohio's PBM. Offerors can meet the size and scope requirement in a number of ways. Possible examples include experience serving comparable populations of covered lives or pharmacy claim volumes as in the Ohio Medicaid managed care program. The examples could also include prior or current PBM projects that are smaller than the Ohio Medicaid Managed Care program but are nevertheless sufficiently significant in size and scope to demonstrate the capability of serving the needs of Ohio. Offerors should provide examples of experience from at least three projects, but Offerors can also submit more than three examples or examples of significant operations plus the ability to scale up operations. When reviewing submissions in response to this requirement, ODM will focus on whether the Offeror's proposed solution has the capacity and capability of performing the required job. 9. Offeror must be a third-party administrator as defined in ORC 5167.01 and meet the requirements to be an Administrator in accordance with Chapter 3959 of the Revised Code at proposal submission. The online application can be found on the Ohio Department of Insurance website. 10. See Answer #9. 11. See Answer #9. 12. Offerors are required to provide the information requested in Template C and Template D. All provisions and systems of the contract are subject to audit. 13. No.

Date: 8/17/2020

Inquiry: 77891


Question:   Would ODM allow for a PBM partnership with an ODM-contracted MCO as the single PBM administrator as contemplated under this RFP and if so would there be any disadvantage to that model that the Department would foresee?

Answer:   ODM acknowledges that numerous types of inter-corporate relationships exist. Offerors are not disqualified merely by the existence of a corporate relationship where a PBM has a direct or indirect corporate relationship with an MCO. These types of corporate relationships, however, implicate the SPBM RFP Pass/Fail Mandatory Requirements when the relevant MCO is or may seek to become an ODM MCO. The Mandatory Requirements state in part that the governance and administration of the SPBM must be completely independent. In the circumstance where these categories of corporate relationships exist, then the Offeror must submit an acceptable Plan of Action. The Plan of Action must detail the actual, potential, or potentially apparent conflict or issue and detail the processes and procedures that the Offeror will undertake to ensure independence, transparency, and objectivity. It remains incumbent on Offerors to comply with the conflicts of interest requirements outlined in Section 1.2 of the RFP. ODM has sole discretion to accept or reject the sufficiency of a proposed Plan of Action and, during the process of evaluation, ODM may seek clarification. If the Plan of Action is rejected, ODM will apprise the Offeror and provide the Offeror the opportunity to retract its RFP response before announcement of the award.

Date: 8/17/2020

Inquiry: 77878


Question:   1. In reference to Section 3.8 Multiple or Alternate Proposals (RFP Base page 17) : May an MCO and an independent PBM partner on a proposal to qualify as an Offeror that would avoid the conflict of interest for bidding? 2. In reference to Section 1.6 Anticipated Procurement Timetable (RFP Base page 10): Due to the compressed timeline of the RFP and COVID-19 restrictions would ODM consider extending the final submission date beyond 9/4 to allow for a more comprehensive response? 3. In reference to Section 4.6 Requirements (RFP Base page 20) As an offeror can we consider a downstream vendor/partner experience to satisfy a mandatory experience qualification? 4. In reference to Section 3.8 Multiple or Alternate Proposal (RFP Base page 17): If an offeror has a subsidiary relationship with a managed care organization is it disqualified from bidding? 5. In reference to Section 3.8 Multiple or Alternate Proposal (RFP Base page 17): May an entity act as a subcontractor for an offeror and also an offeror?

Answer:   This question pertains to Section 3.7, rather than 3.8. ODM acknowledges that numerous types of inter-corporate relationships exist. Offerors are not disqualified merely by the existence of a corporate relationship where a PBM has a direct or indirect corporate relationship with an MCO. These types of corporate relationships, however, implicate the SPBM RFP Pass/Fail Mandatory Requirements when the relevant MCO is or may seek to become an ODM MCO. The Mandatory Requirements state in part that the governance and administration of the SPBM must be completely independent. In the circumstance where these categories of corporate relationships exist, then the Offeror must submit an acceptable Plan of Action. The Plan of Action must detail the actual, potential, or potentially apparent conflict or issue and detail the processes and procedures that the Offeror will undertake to ensure independence, transparency, and objectivity. It remains incumbent on Offerors to comply with the conflicts of interest requirements outlined in Section 1.2 of the RFP. ODM has sole discretion to accept or reject the sufficiency of a proposed Plan of Action and, during the process of evaluation, ODM may seek clarification. If the Plan of Action is rejected, ODM will apprise the Offeror and provide the Offeror the opportunity to retract its RFP response before announcement of the award. 2. ODM is not changing the opening date. If the agency determines at a later date that it will provide additional response time, an RFP addendum will be posted to this website to update the opening date. 3. As a general rule, yes. ODM reserves the right to review the specific arrangement proposed and make a final determination. 4.See Answer #1. 5. This question pertains to Section 3.7, rather than 3.8. Generally, an Offeror can submit a response and also propose to serve as a subcontractor to a separate Offerer. This structure, however, may require the submission of a Plan of Action. The Mandatory Requirements state in part that the governance and administration of the SPBM must be completely independent. The Plan of Action must detail the actual, potential, or potentially apparent conflict or issue and detail the processes and procedures that the Offeror will undertake to ensure independence, transparency, and objectivity. It remains incumbent on Offerors to comply with the conflicts of interest requirements outlined in Section 1.2 of the RFP. ODM has sole discretion to accept or reject the sufficiency of a proposed Plan of Action and, during the process of evaluation, ODM may seek clarification. If the Plan of Action is rejected, ODM will apprise the Offeror and provide the Offeror the opportunity to retract its RFP response before announcement of the award.

Date: 8/17/2020

Inquiry: 77874


Question:   Regarding request SPBM-010.010.040, can you provide the referenced pricing and prior authorization processes for compound drugs?

Answer:   Duplicate of Inquiry 78010.

Date: 8/17/2020

Inquiry: 78024


Question:   OMES-170.000.010. The Contractor must create and maintain end user documentation consistent with any current ODM standards. Can you provide the current ODM standards, or point out where they are included in the Bidders Library?

Answer:   ODM does have user documentation standards and these will be provided to the selected Offeror during the implementation phase.

Date: 8/17/2020

Inquiry: 78016


Question:   SPBM RFP Base-Proposal Requirements and Format: ODM identifies a response to Supplement 6 and Supplement 7 included in the tabbed sections: Each Proposal must be organized in an indexed binder with tabs labeled and ordered in the manner listed below. The Proposal must include the following tabbed sections:  Template A – Cover Letter, Executive Summary, and Subcontractor Letters  Template B –Terms and Conditions  Template C – Offeror Profile  Response to Supplement One  Response to Supplement Three  Response to Supplement Four  Response to Supplement Six  Response to Supplement Seven  Template D – Administrative Forms  Template E – Assumptions  Template F – Cost Proposal Workbook (Must be separately sealed) However, states in a recent answer, that there are no requirements to include tabs for Supplment 6 and Supplment 7. Is the contractor expected to provide tabs in the Technical Response?

Answer:   There is no requirement to include tabs for Supplements 6 and 7.

Date: 8/17/2020

Inquiry: 78015


Question:   Regarding request SPBM-010.010.040, can you provide the referenced pricing and prior authorization processes for compound drugs?

Answer:   The Compound Prior Authorization form is available at: https://pharmacy.medicaid.ohio.gov/sites/default/files/Compound_PA_Form.pdf#overlay-context=prior-authorization. Processing information for compound drugs is available in the ODM Pharmacy Provider Manual Billing Procedure Guide at: https://pharmacy.medicaid.ohio.gov/sites/default/files/202007_Provider_Manual_FINAL.pdf#overlay-context=pharmacy-billing-information.

Date: 8/17/2020

Inquiry: 78010


Question:   Regarding Contract solution OMES-130.020.010, What is the timeline on which the data will be provided? What quality and controls does the state have in place?

Answer:   Requirement OMES-130.020.010 is for the Offeror to develop and deliver a data conversion plan based upon the Offeror's solution and identified OME and other data sources. This is to be completed during Phase 2 - Solution Planning.

Date: 8/17/2020

Inquiry: 78009


Question:   Supplement One, Section 1 Question: ODM indicates there are approximately 40,000 PAs processed by the combined PBMs. Can ODM confirm if overrides are included in this count?

Answer:   These prior authorization estimates do not include overrides and ODM is not able to provide PA override volumes.

Date: 8/17/2020

Inquiry: 77996


Question:   Supplement Six, Member Materials and Template F Question: The requirement in Supplement Six, 3.3 states that contractor is required to provide new member materials for the MCOs to distribute and an insert to be included with each MCOs member handbook. Is it the expectation that the Contractor provide hard copy of the insert to the Member Handbook to the MCO, or just the information in electronic form to be included in their files? There is a line item for member handbook in Template F, Implementation Deliverables Task Group 6 (Item 44) - does this line item refer to content development only or also include supplying hard copy member handbooks to the MCOs?

Answer:   Item 44 in Template F pertains to the costs of developing and communicating content electronically to the MCOs.

Date: 8/17/2020

Inquiry: 77992


Question:   Supplement Six, Section 3.2 Question: Please clarify the translation services the SPBM contractor must provide to members per requirement 3.2.c on page 14 and OAC rule 5160-26-05.01. The RFP requirement states "the Contractor must contract with local agencies to provide such services" while the rule appears to address MCOs as being responsible.

Answer:   The rule requires the SPBM to develop mutual policies between them and a network provider regarding obligations to provide oral translation, oral interpretation, and sign language services - including whether or not the SPBM or the provider will be financially responsible for those services. If the SPBM and provider agree that the SPBM will be responsible for these services, then in accordance with Supplement 6, 3.2(c), the SPBM must use a local agency to provide the services.

Date: 8/17/2020

Inquiry: 77990


Question:   Question in regards to OMES-320.010.070: The link referenced in ODM IPP 4501 for the retention schedule is invalid. Can you confirm that the retention period for ODM should align with the Ohio General Schedule List found at https://apps.das.ohio.gov/RIMS/GeneralSchedule?

Answer:   The ODM retention schedules can be found at the following link: https://apps.das.ohio.gov/RIMS/Schedule

Date: 8/17/2020

Inquiry: 77980


Question:   Question in regards to OMES-320.010.020: The SOC 2 does not specify which controls are required – is ODM’s expectation that the SOC includes all 5 controls?

Answer:   Yes, all five controls must be included.

Date: 8/17/2020

Inquiry: 77979


Question:   Relevant RFP Part - Document Name: SPBM RFP Base Relevant RFP Part (Section/Sub-Section): 6.3 Heading for Provision being Questioned: Attachment Three: Requirements for Proposal RFPPage #: 39 Question: On page 39, under “Proposal Requirements and Format,” says “All pages, except pre-printed technical inserts, must be sequentially numbered.” The language context in the same paragraph might make it reasonable to infer that such a requirement is section-by-section, not the entire proposal. Will ODM please confirm that sequential proposal page numbering is applicable by section only?

Answer:   Confirmed.

Date: 8/17/2020

Inquiry: 77967


Question:   Relevant RFP Part-Document Name: SPBM RFP Base, Supplements, One & Seven Relevant RFP Part (Section/Sub-Section): 6.3 Heading for Provision being Questioned: Attachment Three: Requirements for Proposal RFP Page #: 39,40 Question: Supplement Seven, Draft Managed Care Rules, is listed as a required tab on page 39. Table 5 instructions, which begin on page 40 of the RFP, omits mention of this supplement. Based on Q&A, it appears that the response for Supplement Seven should be included in the response to Supplement One. Is it ODMs intent to form a complete contract package for award and if so, does the RFP Supplement Seven belong behind the Supplement Seven Tab for the submittal?

Answer:   There are no specific responses required for Supplement 7. Offerors are not required to include a copy of Supplement 7 in their responses.

Date: 8/17/2020

Inquiry: 77966


Question:   Relevant Part of RFP-Documnet Name: SPBM RFP Base, Supplements, One & Six Relevant RFP Part (Section/Sub-Section) : 6.3 Heading for Provision being questioned: Attachment Three: Requirements for Proposal RFP Page #: 39,40 Question: Supplement Six, Additional Managed Care Criteria, is listed as a required tab. Table 5 instructions, which begin on page 40 of the RFP, omits mention of this supplement. Based on Q&A, it appears that the response for Supplement Six should be included in the response to Supplement One. Is it ODMs intent to form a complete contract package for award and if so, does the RFP Supplement Six belong behind the Supplement Six Tab for the submittal?

Answer:   There are no specific responses required for Supplements 6. Offerors are not required to include a copy of Supplement 6 in their responses.

Date: 8/17/2020

Inquiry: 77965


Question:   Supplement 1, Scope of Work, Claims Processing, SPBM-010.040.080 - Page 38 Questions: The RFP States, "The Contractor must adjudicate 100% of provider-initiated paper claim adjustment requests within fourteen (14) calendar days of receipt." Please provide the anticipated monthly volumes.

Answer:   Historically, fewer than 100 paper claims per month are received.

Date: 8/17/2020

Inquiry: 77954


Question:   Question regarding SPBM-070.010.020, there is a reference to Supplement 6, Section 4.6 which speaks to Timely Access. It appears Supplement 6, Section 4.5, specifically part b. Notice to Members is more applicable. Please confirm requirements in Supplement 6, Section 4.5, should be used to respond to SPBM-070.010.020.

Answer:   Confirmed.

Date: 8/14/2020

Inquiry: 78007


Question:   SPBM-160-100-150-The Contractors Solution must have functionality to provide ODM-authorized users real-time, online access related to financial operations and processes )e.g., payables, receivables, disbursements cycle totals and status). Question: Can ODM provide clarity around this requirement. Is ODM requiring access to the accounting software application?

Answer:   The Offeror must provide read-only access to any and all components of the solution that would be required by ODM to monitor financial activity. The Offeror must propose what solutions components will be accessed and how access will be restricted to specific ODM-authorized users.

Date: 8/14/2020

Inquiry: 78004


Question:   SLA 29 Performance of Outbound Requests Can ODM describe the nature of the outbound requests that the Contractor will be expected to support and perform?

Answer:   Any request for Customer Service Center data from an organization other than ODM.

Date: 8/14/2020

Inquiry: 78002


Question:   OMES-220.030.120 The Contractor must support testing activities of other OMES modules as required by ODM. Question: Can ODM elaborate on other OMES modules and what kind of support testing activities are required?

Answer:   The offeror will be required to support all testing activities that involve the Fiscal Intermediary functions. Current plans would include the System Integrator, Provider Network, and various internal applications. Testing will also be required to support the integration of managed care organizations and the pharmacy benefit manager. There may be additional integrations which require testing that are yet to be determined.

Date: 8/14/2020

Inquiry: 78001


Question:   SPBM-030.020.070 The Contractor’s solution must have functionality to automatically prepare and transmit correspondence (e.g., invoices for new amounts owed, periodic statements of account, notification of debt satisfaction) to account holders (e.g., provider, individuals, MCOs) with receivable balances, based on ODM-defined business rules. Question: Please provide examples of when we would need to notify MCOs and individuals

Answer:   MCOs would need notification of any financial liability associated with services, such as quality improvement initiatives, that would be contracted by the MCO and paid to the participating pharmacies. Individuals would need to be notified of any patient liability.

Date: 8/14/2020

Inquiry: 78000


Question:   SPBM-010.010.130 The Contractor must adjudicate primary and coordinated benefit pharmacy claims for ODM’s current programs and any future programs consistent with ODM’s coverage and reimbursement policies and procedures. Question: When it comes to COB which scenario will a contractor be expected to use for Claims Processing?

Answer:   ODM currently uses Scenario 3 (Government Programs) for FFS claims submitted using the NCPDP Telecom Standard vD.0, but there is no determination that will apply to the SPBM. The Offeror should be prepared to support all scenarios defined in the HIPAA-named standards.

Date: 8/14/2020

Inquiry: 77999


Question:   SPBM-010.010.270 The Contractor must develop and maintain NCPDP-compliant cost avoidance and Third-Party Liability (TPL) edits that conform to federal and state regulations to ensure that Medicaid is the payer of last resort, as appropriate or required. Question: How will the contractor receive TPL edits?

Answer:   Requirement SPBM-010.010.270 pertains to the Offeror's solution to use third party liability information in the adjudication of pharmacy claims. The Offeror must describe how their proposed solution performs this functionality.

Date: 8/14/2020

Inquiry: 77998


Question:   Supplement One, Table 16 Question: Please confirm that Table 16 Security Requirements contains the complete list of requirements. It appears that some requirement numbers were omitted. For example, OEMS-140.000.090 is followed by OEMS-140.000.270 and the next requirement is 140.000.330.

Answer:   Requirement IDs are not a sequential list and are for label reference only. All requirements are included in the RFP.

Date: 8/14/2020

Inquiry: 77997


Question:   Supplement Six, Section 3.3 and Template F Question: In section 3.3.c, Member ID cards are to be issued by ODM. Please clarify whether the line item in Template F, Implementation Deliverables (item 42) refers to development of content or something different.

Answer:   Item 42 in Template F pertains to the costs of developing and communicating content to ODM.

Date: 8/14/2020

Inquiry: 77993


Question:   RFP Base, Section 6.3, Attachment Three Question: Would the State please confirm that it is permissible for vendors’ proposal pages to be sequentially numbered per tabbed section?

Answer:   Confirmed.

Date: 8/14/2020

Inquiry: 77991


Question:   Question regarding SPBM-070.030.040: Under 5.11(b)(iii), please confirm that Contractor does not need to notify ODM for proposed recovery of funds due to audit where ODM has approved audit recovery template letter since audits may recover small numbers of claims across multiple pharmacies.

Answer:   No, the approval of the audit recovery template is not sufficient; the Offeror must obtain ODM approval before recovering funds after an audit to avoid duplicate recovery efforts by other entities.

Date: 8/14/2020

Inquiry: 77987


Question:   Question regarding SPBM-070.030.030: Under Section 5.9(c)(ix), a description is required to track and ensure 3% of total pharmacy expenditures are subject to post-payment investigation. Please confirm that this expenditure calculation is dependent upon investigations and audits which ODM has approved and are post-stand down/post-deconfliction.

Answer:   The 3% of expenditures reviewed may include both desk audits conducted without need for deconfliction and audits conducted after deconfliction is required.

Date: 8/14/2020

Inquiry: 77986


Question:   Question regarding SPBM-070.000.010: Section 5.10 does not state if pharmacy desktop audits are included in the reporting requirements for Fraud, Waste, or Abuse. Will audits be permitted without initial referral so that audit may determine suspected fraud, waste, or abuse for Contractor’s subsequent referral? Please confirm that these are excluded from this referral reporting.

Answer:   Assuming the desktop audit does not require the request of provider records, the Offeror is permitted to move forward without a request for deconfliction. The PBM would need to make a referral to ODM when it identifies suspected fraud, waste, or abuse, or need to request deconfliction to recover an overpayment if the desk audit results in a potential overpayment that does not rise to the level of fraud, waste, or abuse.

Date: 8/14/2020

Inquiry: 77985


Question:   Question regarding SPBM-070.000.010: Section 5.10 includes several approval/clearances on conducting investigations, audits and reviews including (b)(iii) (d)(i-iii) to prevent conflict with law enforcement investigation. These requirements as written significantly delay timely performance of audit and investigations and reporting achievement on the pharmacy expenditures threshold outlined in Section 5.9. Will initial post-payment investigations without outreach to a pharmacy or prescriber be permitted so that investigators may expedite resolution of the investigation once stand-down/deconfliction release is provided?

Answer:   Duplicate of Inquiry 77983.

Date: 8/14/2020

Inquiry: 77984


Question:   Question regarding SPBM-070.000.010: Section 5.10 includes several approval/clearances on conducting investigations, audits and reviews including (b)(iii) (d)(i-iii) to prevent conflict with law enforcement investigation. These requirements as written significantly delay timely performance of audit and investigations and reporting achievement on the pharmacy expenditures threshold outlined in Section 5.9. Will initial post-payment investigations without outreach to a pharmacy or prescriber be permitted so that investigators may expedite resolution of the investigation once stand-down/deconfliction release is provided?

Answer:   Yes, the Offeror can conduct a post-payment investigation with data in its possession before requesting deconfliction. Deconfliction is required when the PBM is to take an action that would alert the provider that it is the subject of an audit, investigation, or review for program integrity reasons, or before recovering an overpayment.

Date: 8/14/2020

Inquiry: 77983


Question:   Relevant RFP Part - Document Name: Supplement One: Scope of Work Relevant RFP Part (Section/Sub-Section): 4.2 Heading for Provision being Questioned: Utilization Management RFP Page #: 52 Question: SPBM-020.040.150: The Contractor must migrate, successfully, all existing automated PAs into Contractor’s automated prior authorization application. From the legacy systems of multiple entities, the Contractor must import and honor for use in real-time claims processing all existing prior authorizations that have not expired regardless of whether they were manually or electronically approved. Will the source or sources of existing automated prior authorizations be required to provide those prior authorization records in a single standard, ODM or awarded SPBM Vendor provided, format?

Answer:   The Offeror should assume that they will need to convert the existing prior authorizations from up to five (5) legacy systems.

Date: 8/14/2020

Inquiry: 77976


Question:   Relevant RFP Part - Document Name: Supplement One: Scope of Work Relevant RFP Part (Section/Sub-Section): 4.2 Heading for Provision being Questioned: Utilization Management RFP Page #: 48 Question: SPBM-020.030.010: The Contractor must actively participate and coordinate with ODM and the MCOs for CSP member monitoring as well as CSP performance measurement and program evaluation. Please describe the nature and scope of CSP member monitoring coordination with contracted MCOs.

Answer:   The Offeror must coordinate with the MCOs in order to identify eligible CSP members, assign providers and CSP timeframes, as well as provide reports and emergency overrides in the point of sale system when necessary.

Date: 8/14/2020

Inquiry: 77975


Question:   Relevant RFP Part - Document Name: Supplement One: Scope of Work Relevant RFP Part (Section/Sub-Section): 4.2 Heading for Provision being Questioned: Utilization Management RFP Page #: 48 Question: SPBM-020.020.070: The Contractor must have the capability to, as directed by ODM, implement a suite of technical prescriber tools/electronic prescribing systems  such as but not limited to SureScripts/RxHub®, health information exchanges, Epocrates® etc. to maintain and support the PDL, prior authorizations, and coverage details of the ODM’s programs. Q: Please provide a count of health information exchanges that are currently integrated with prescriber tools or ePrescribing solutions not obtained through HIE to Surescripts/RxHub connectivity. For those identified, is ODM the contracted entity to the health information exchange?

Answer:   The Offerors must propose how they will effectively and efficiently implement technical prescriber tools/electronic prescribing systems.

Date: 8/14/2020

Inquiry: 77974


Question:   Relevant RFP Part - Document Name: Supplement 6 Relevant RFP Part (Section/Sub-Section): 3.2 Heading for Provision being Questioned: Member Information RFP Page #: 13-14 Question: 3.2 c and 3.2 d are duplicated in this section. Please clarify if the second set is intended to be 3.e and 3.f so we may address accordingly in our response.

Answer:   There is a formatting error in Supplement 6 and the second occurrence of Section 3.2.c and Section 3.2.d should be Section 3.2.e and Section 3.2.f, respectively. There are no specific responses required for Supplements 6.

Date: 8/14/2020

Inquiry: 77972


Question:   Relevant RFP Part - Document Name: Supplement One: Scope of Work Relevant RFP Part (Section/Sub-Section): 6.4 Training Heading for Provision being Questioned: OMES-230.030.030 RFP Page #: 142 Question: This requirement specifies that "The Contractor must provide ODM-approved staff, knowledgeable of the module and related components, to perform training." Please specify if there is a specific ODM standard for the required educational level, skills, and qualifications of the "ODM-approved staff" referenced by this requirement.

Answer:   The Offeror is expected to propose the training staff that are experienced trainers, well versed in the Offeror's solution.

Date: 8/14/2020

Inquiry: 77971


Question:   Relevant RFP Part - Document Name: Supplement One: Scope of Work Relevant RFP Part (Section/Sub-Section): 5.8 User Documentation Heading for Provision being Questioned: OMES-170.000.010 RFP Page #: 123 Questions: This requirement specifies that "The Contractor must create and maintain end user documentation consistent with any current ODM standards." Please specify if there is a specific ODM standard covering user documentation or whether the reference applies only to incidental standards in other ODM documents such as required contents of a document, etc.

Answer:   ODM does have user documentation standards and these will be provided to the selected Offeror during the implementation phase.

Date: 8/14/2020

Inquiry: 77970


Question:   SPBM Base RFP 6.1 Attachment One Cost - Page 31 Question: Can the State provide guidance on the overall budget of this procurement or provide a range for estimated annual operations?

Answer:   ODM does not provide budget information in advance of proposal submissions. Offerors are expected to provide their best price based on the scope of work and level of effort.

Date: 8/14/2020

Inquiry: 77948


Question:   SPBM Base RFP 6.1 Attachment One Scoring Veterans Enterprise Preference - Page 33 Question: Can the State provide guidance as to the number of eligible points and the target threshold for Veteran participation?

Answer:   ODM will apply the Veteran-Friendly Business Enterprise (VFBE) preference or bonus points to an Offeror that is certified as a VFBE, as required by ORC § 9.318 and OAC § 123:5-1-16. No VFBE subcontracting requirement exists in this RFP.

Date: 8/14/2020

Inquiry: 77947


Question:   Please elaborate on ODM’s expectation/definition of ‘Therapeutic Interchange’ and its use in clinical programs.

Answer:   Therapeutic interchange is the practice of replacing, with the prescriber’s approval, a prescription medication originally prescribed for a patient with a chemically different medication. A clinical program may include sending messaging to pharmacies about lower cost or improved patient care alternatives.

Date: 8/14/2020

Inquiry: 77923


Question:   Testing Requirements:OMES-220.030.120-The Contractor must support testing activities of other OMES modules as required by ODM. Can the State elaborate on other OMES modules that the contractor would need to support testing activities for? What kind of support testing activities are required?

Answer:   The offeror will be required to support all testing activities that involve the Fiscal Intermediary functions. Current plans would include the System Integrator, Provider Network, and various internal applications. Testing will also be required to support the integration of managed care organizations and the pharmacy benefit manager. There may be additional integrations which require testing that are yet to be determined.

Date: 8/14/2020

Inquiry: 77918


Question:   Supplement 1, Scope of Work, Claim Review, SPBM-050.010.120 - Page 76 Question: "The RFP States, ""The Contractor must perform a desk or onsite claim review on an ad hoc basis, if requested to do so by ODM." Can the State please provide the estimated number of desk reviews?

Answer:   ODM is unable to provide volumes for desk reviews. Offerors are encouraged to investigate industry standards to model these volumes.

Date: 8/14/2020

Inquiry: 77949


Question:   Supplement One, Finance Management, SPBM-030.020.010 Question: For Requirement SPBM-030.020.010, how many staff does the current contractor maintain for all checkwrite and accounts receivable functionality?

Answer:   There is no incumbent for this procurement.

Date: 8/13/2020

Inquiry: 77995


Question:   Base RFP, Section 1.6 Question: Due to complexity of this RFP and in order for offerors to provide the most complete response to ODM, would ODM consider extending the proposal due date by three weeks?

Answer:   ODM is not changing the opening date. If the agency determines at a later date that it will provide additional response time, an RFP addendum will be posted to this website to update the opening date.

Date: 8/13/2020

Inquiry: 77994


Question:   Supplement One, SPBM-020.040.130 Question: The Contractor must notify the recipient when PA is denied. Will ODM provide the number of denied PAs on a monthly, quarterly or annual basis, please?

Answer:   There were approximately 153,000 denied prior authorizations for managed care members during calendar year 2019.

Date: 8/13/2020

Inquiry: 77989


Question:   RFP Base, Section 6.3. Attachment 3 Question: Follow-up question to inquiry #77863. The RFP indicates that the proposal must include tabbed sections.  The list of sections includes: -- Response to Supplement Six -- Response to Supplement Seven In light of the response to Question 77863 that indicates that there are no specific responses to Supplements Six and Seven, are these tabbed sections required to be included in bidders’ proposals? Are bidders required to submit these two supplements as part of their proposals?

Answer:   There is no requirement to include tabs for Supplements 6 and 7.

Date: 8/13/2020

Inquiry: 77988


Question:   Question in regards to OMES-320.010.070: The policy specifies a requirement for each ODM office/bureau/facility including a Records Coordinator, record destruction, use of OmniRIM for records management and coordination with the JFS Records Center. Will the Contractor be considered an office/bureau/facility of ODM?

Answer:   No.

Date: 8/13/2020

Inquiry: 77981


Question:   Relevant RFP Part - Document Name: Supplement One: Scope of Work Relevant RFP Part (Section/Sub-Section): 4.3 Heading for Provision being Questioned: Finance Management RFP Page #: 56 Question: SPBM-030.010.040: The Contractor’s solution must capture and maintain MCO financial participation in payments to providers enrolled with ODM. The Contractor must make details of the MCO financial transactions available to ODM upon request. Q: Please provide additional detail regarding Contractors responsibilty and scope of work required to "capture and maintain MCO financial participation in the payments to providers enrolled with ODM".

Answer:   MCO financial participation in payments would be for services not included in pharmacy claims. These would be payments for other services, such as quality improvement initiatives, that would be contracted by the MCO and paid to the participating pharmacies. The cost of these services will not be reimbursed by ODM to the SPBM, therefore needs to be financially accounted for separately.

Date: 8/13/2020

Inquiry: 77977


Question:   Relevant RFP Part - Document Name: SPBM RFP Base Relevant RFP Part (Section/Sub-Section): 3.5 Heading for Provision being Questioned: Proposal Submittal RFP Page #: 15, 16 Question: The RFP requires, " The Technical Proposal package must be sealed and contain one (1) originally signed and eight (8) paper copies, and one (1) digital copy (CD-ROM/USB) of the Technical Proposal. ODM prefers the digital copy be a single pdf document. If this is not possible, use as few pdf documents as possible." The RFP also requires, "The Cost Proposal package must contain one (1) original and one (1) paper copy, and one (1) digital copy (CD-ROM/USB) of the of the Cost Proposal." Providing an this many paper copies requires extensive coordination and resources. Because of the world’s current situation related to COVID and constraints on travel, material and supply availability, sheltering in place and working in close proximity to others, will ODM please accept an electronical proposal submittal and waive the requirement for hard copy documents?

Answer:   No.

Date: 8/13/2020

Inquiry: 77969


Question:   Please provide clarification on SPBM-180.100.070. How do you define "processing errors?"

Answer:   Processing errors would be failures to correctly adjudicate and pay claims, for example due to programming errors or incorrect reference files.

Date: 8/13/2020

Inquiry: 77963


Question:   Supplement 1, Scope of Work, Claims Processing, SPBM-010.010.360 - Page 33 Question: The RFP States, ""The Contractor must manually review and approve or deny within twenty-four (24) hours 100% of multi-ingredient compounded claims that exceed the established dollar limit threshold in order to validate the medical necessity of the compound, commercial availability, and other clinical criteria approved by ODM." Please provide the estimated monthly volumes for compound drug claims.

Answer:   ODM is unable to provide volumes for compound-drug claims that exceed the established dollar limit threshold. Offerors are encouraged to investigate industry standards to model these volumes.

Date: 8/13/2020

Inquiry: 77956


Question:   Supplement 1, Scope of Work, Claim Review, SPBM-050.000.090 - Page 73 Question: The RFP States, ""The Contractor must manually review all claims for providers placed on prepayment review status as requested by ODM in accordance with ODM policy. Please provide the estimated volumes for this activity.

Answer:   ODM is unable to provide volumes for claims reviews due to placement on prepayment review status. Offerors are encouraged to investigate industry standards to model these volumes.

Date: 8/13/2020

Inquiry: 77952


Question:   Supplement 1, Scope of Work, Claim Review, SPBM-050.000.190 - Page 74 Question: The RFP States, "The Contractor must implement a high-dollar claim review process for high-cost specialty drugs or other therapies as directed by ODM." Please provide the estimated volumes for this activity.

Answer:   ODM is unable to provide volumes for high-dollar claims reviews. Offerors are encouraged to investigate industry standards to model these volumes.

Date: 8/13/2020

Inquiry: 77951


Question:   SPBM Base RFP Document Section 1.6 Anticipated Procurement Timetable - Page 10 Question: Given the complexity and number of requirements of the RFP, the scope of the proposal production effort, and the critical importance of these services, will the State consider moving the proposal due from September 4, 2020 to September 25, 2020 to allow all interested vendors a fair opportunity to deliver an accurate and cost-effective proposal for this scope of work?

Answer:   ODM is not changing the opening date. If the agency determines at a later date that it will provide additional response time, an RFP addendum will be posted to this website to update the opening date.

Date: 8/13/2020

Inquiry: 77946


Question:   1. In reference to Section 4.1 Claims Processing (Supplement 1- Scope of Work, page 27): The Claim Processing Requirement (SPBM-010.010.010) states that the Contractor’s solution must provide claim and eligibility processing services that are compliant with current and future HIPAA-adopted Transactions and Code Sets standards. Is the requirement that the Offeror’s system allow HCPCS codes to be submitted through the NCPDP Telecom Standard? 2. In reference to Section 4.1 Claims Processing (Supplement 1- Scope of Work, page 29): The Claim Processing Requirement (SPBM-010.010.110) states that the Contractor’s solution must minimally support the ability to track and report on the specific adjudication rule in effect by date of service and date of payment, and the date the rule was changed, added or deleted. Is this tracking expected to be done on an individual claim basis or is pulling a report from the clinical rules system sufficient? 3. In reference to Section 4.1 Claims Processing (Supplement 1- Scope of Work, page 29): The Claim Processing Requirement (SPBM-010.010.110) states that the Contractor’s solution must minimally support adjudication rules customized for each supported program by category codes… Can you please provide an example of how ODM may desire to customize an adjudication rule by category code? 4. In reference to Section 4.1 Claims Processing (Supplement 1- Scope of Work, page 29): The Claim Processing Requirement (SPBM-010.010.110) states that the Contractor’s solution must minimally support adjudication rules customized for each supported program by eligibility status… Can you please provide an example of how ODM may desire to customize an adjudication rule by eligibility status? 5. In reference to Section 4.1 Claims Processing (Supplement 1- Scope of Work, page 30): The Claim Processing Requirement (SPBM-010.010.150) states that the Contractor must maintain detailed electronic documentation outlining the specific benefit design structure that supports and represents ODM’s pharmacy benefits in the Contractor’s system. Please clarify what is meant by "detailed electronic documentation outlining the specific benefit design structure that supports and represents ODMs pharmacy benefits in the Contractors system." Will benefit design documentation that corresponds to clinical rule setup in the PBM system serve as adequate electronic documentation? 6. In reference to Section 4.1 Claims Processing (Supplement 1- Scope of Work, page 31): The Claim Processing Requirement (SPBM-010.010.260) states that the Contractor must maintain claim edits that enforce ODM-specified conditions to be met for claims payment. Please clarify the ODM-specified conditions required for claims payment for which you desire claim edits to be in place. For example, do you require all fields to have valid NCPDP values, a provider to be contracted, etc. prior to claims payment? 7. In reference to Section 4.1 Claims Processing (Supplement 1- Scope of Work, page 35): The Claim Processing Requirement (SPBM-010.020.020) states that the Contractor must validate claims to determine whether there is a liable third party (or parties) that must be billed prior to billing ODM including utilizing ODM eligibility and supplemental TPL data, Contractor’s TPL resources, and any other available sources of TPL data to ensure that all prior payment opportunities are utilized. If the SPBM has a contract with an external vendor to use for third party liability identification, can the SPBM use that vendor to review ODM claims to identify other potential sources of TPL information to supplement ODMs?

Answer:   1. The Offeror is required to support current and future HIPAA-adopted NCPDP standards, including all of the approved Code Sets. 2. The expectation is that the adjudication rules used to process a specific claim can be accurately reported at any time. 3. Claims adjudication rules must be able to vary based upon the member's eligibility aid category, such as Medicaid Expansion, Covered Families and Children (CFC), Aged, Blind and Disabled (ABD), etc. 4. Claims adjudication rules must be able to vary based upon the member's eligibility status, such as Presumptive, Deemed or otherwise eligible. 5. The expectation is that all claims processing rules be documented in detail and available to ODM authorized resources electronically on-demand. The offeror must propose the most efficient and effective method to accomplish this requirement. 6. ODM is unclear about the reference of this question. Offeror may submit a new question clarifying the requested information. 7. Yes, with prior approval of the external vendor by ODM.

Date: 8/13/2020

Inquiry: 77944


Question:   1. In reference to Section 1 Overview of Single Pharmacy Benefit Manager Module (Supplement 1- Scope of Work, page 1): The document states that the SPBM will not be at financial risk for changes in utilization and providers will be compensated using a transparent pass-through method of payment of ingredient cost and any applicable fees paid to the pharmacy funded by ODM. Is PBM at financial risk for drug cost changes? Utilization is only one component of drug spend. 2. In reference to Section 1 Overview of Single Pharmacy Benefit Manager Module (Supplement 1- Scope of Work, page 2): The high-level ODM objectives, priorities, and vision for future SPBM services in the OMES include increasing Medicaid Information Technology Architecture (MITA) maturity and maintaining an emphasis for the reuse of solutions by implementing the SPBM through a SaaS model that is shared with other entities. Can you help us better understand how ODM envisions the SPBM sharing the SaaS model with other entities – through APIs or through cloud-based technology? 3. In reference to Section 1 Overview of Single Pharmacy Benefit Manager Module (Supplement 1- Scope of Work, page 2): ODM expects the implementation of the SPBM module to facilitate the decommissioning of existing Medicaid Managed Care Pharmacy services (not including MyCare) and provide the modular architecture necessary to facilitate the transition of additional Medicaid functions to the new OMES architecture. Can you help us understand the modularity of vendor systems and what ODM envisions here for transitioning of functions to OMES? 4. In reference to Section 1 Overview of Single Pharmacy Benefit Manager Module (Supplement 1- Scope of Work, page 3): In Figure 1- Initial SPBM Vision, does SPBM handle only drugs processed through the pharmacy benefit, or any covered outpatient drugs that are physician-administered and/or paid through the medical benefit (e.g. blood factor, specialty drugs, etc)? 5. In reference to Section 1 Overview of Single Pharmacy Benefit Manager Module (Supplement 1- Scope of Work, page 3): The document states that the contracted PBMs perform all associated services including, but not limited to, claims processing and payment of approximately 45 million paid claims annually (calendar year 2019), utilization management, claim review, and provider network management. Approximately how many claims are there annually for FFS Medicaid? 6. In reference to Section 1 Overview of Single Pharmacy Benefit Manager Module (Supplement 1- Scope of Work, page 3): The document states the contracted FFS PBM submits adjudicated FFS pharmacy claims to ODM, at a minimum weekly, where payment of the claims is completed. The FFS PBM vendor is currently responsible for FFS claims processing, claim review, prior authorization management, utilization management, drug rebate administration for all Medicaid (MCO and FFS) claims, and PDL management. When the FFS Medicaid members move to the SPBM in Year 2, will ODM require the SPBM to pay pharmacies out of the ODM checking account or will ODM handle provider payments?

Answer:   1. The SPBM will not be at financial risk for costs associated with utilization or drug costs. 2. The OMES has multiple forms of transmitting and receiving data and reporting. The primary means are through the System Integrator using webservices in a publish and subscribe model, batch file transfer via SFTP, and EDI transactions. The offeror is expected to support all defined communications protocols. 3. Please refer to "Conceptual Module Architecture of the OMES", RFP Base, Pages 5 -6, for additional information regarding OMES. 4. The ability to accept, price, and process physician-administered drug claims, applying the same edits and UM criteria as those applied to an NCPDP pharmacy claim, and/or additional edits as specified by ODM, is a future goal and potential functionality (Supplement 1 - Scope of Work, Page 83). 5. For calendar year 2019, approximately 4.5 million FFS claims were paid. 6. When FFS pharmacy claims processing is transitioned to the SPBM, the payments will be made to the pharmacies using the same processes as the managed care member claims.

Date: 8/13/2020

Inquiry: 77943


Question:   Supplement 1, OMES 320.010.070 Can you provide a link to the ODM-IPP 4501 Records Management Policy?

Answer:   ODM does not have an online link to this document. Any Offeror that wants a copy of the document can request it by submitting an email to mcdlegal@medicaid.ohio.gov.

Date: 8/13/2020

Inquiry: 77939


Question:   Supplement 1 Scope of Work Section 2.9 Proposed Work Plan and Schedule - Page 22 Question: "The RFP states, ""A network diagram showing the planned start and end dates for all tasks and subtasks indicating the interrelationships of all tasks and subtasks and identifying the critical path. An electronic file of the detailed Project Schedule should be provided with the RFP response as well as a printed copy."" Since a network diagram can be extremely large will the State accept a WBS Chart that depicts the same information to meet this requirement?

Answer:   No. ODM believes that the Network Chart is the best way to convey how the Offeror is structuring the project chronologically.

Date: 8/12/2020

Inquiry: 77957


Question:   Supplement 1, Scope of Work, Claims Processing, SPBM-010.090.040 - Page 44 Question: The RFP states, "The Contractor must provide transaction management to support all business processes of the solution as specified by ODM." Please provide more detail regarding this requirement, specifically what is meant by the term transaction management.

Answer:   The offeror must process all current and future applicable HIPAA standard electronic transactions.

Date: 8/12/2020

Inquiry: 77955


Question:   Supplement 1, Scope of Work, Customer Service Center, SPBM-040.000.040 - Page 61 Question: The RFP States, "The Contractor must utilize an ODM-provided in-bound telephone number and fax number for the CSC." Please confirm that ODM will own these phone numbers and will assign the Contractor as an agent to manage them.

Answer:   ODM confirms that ODM will own the Customer Service Center phone numbers and provide them to the Offeror to manage.

Date: 8/12/2020

Inquiry: 77953


Question:   Supplement 1, Scope of Work, Claim Review, SPBM-050.010.040 page 75 Question: The RFP States, "The Contractor must utilize initial claim review request letters that clearly define the ODM rationale for identified overpayments, including a citation of the applicable statute, rule or manual section." Please provide the estimated volumes for this business activity.

Answer:   ODM is unable to provide call volumes for the member and pharmacy help desk. Offerors are encouraged to investigate industry standards to model call volumes.

Date: 8/12/2020

Inquiry: 77950


Question:   Question regarding SPBM-040.000.180: 99% first call resolution is extremely high. How is this measured?

Answer:   Refer to Template B - Terms and Conditions: SLA 27 Service Desk Call Resolution (Page 24).

Date: 8/12/2020

Inquiry: 77938


Question:   Question regarding SPBM-040.000.070: Can ODM confirm the pharmacy informational materials required to be provided to caller upon request?

Answer:   It is anticipated that callers may request any publically available printed materials via the Interactive Voice Response (IVR) system.

Date: 8/12/2020

Inquiry: 77937


Question:   Question regarding SPBM-040.000.070: Can ODM provide the self-service options?

Answer:   Offerors should propose what self-service options are supported by their Interactive Voice Response (IVR) system.

Date: 8/12/2020

Inquiry: 77936


Question:   Question regarding SPBM-040.000.070: Can ODM provide the criteria for recorded calls?

Answer:   This requirement specifies the functionality of the Interactive Voice Response (IVR) system. "Recorded information" would be general announcements or responses to caller selections, such as a list of pharmacy informational materials that may be requested.

Date: 8/12/2020

Inquiry: 77935


Question:   Question regarding SPBM-040.000.050: It is unknown how long COVID restrictions will be in play. Will we be allowed to leverage virtual workforce as long as they reside in Ohio?

Answer:   The requirement is to have the primary Customer Service Center (CSC) site in the State of Ohio. Offerors must adhere to the COVID-19 guidance provided and updated by the State of Ohio in meeting this requirement (refer to https://coronavirus.ohio.gov/).

Date: 8/12/2020

Inquiry: 77934


Question:   Claim Review-SPBM-050.000.070-For this requirement, is it ODMs intent to have a separate pharmacy billing manual and a claims review provider manual or is it the intent that all claims processing, billing, and claims review processes be maintained within the same manual?

Answer:   The offeror should propose the solution they consider most efficient and effective.

Date: 8/12/2020

Inquiry: 77928


Question:   If the medical claims are not going to come from ODM, will each MCO be required to utilize a single file format and be responsible for any costs associated with set-up and design?

Answer:   It is anticipated that medical claims data would provided through the OMES System Integrator.

Date: 8/12/2020

Inquiry: 77922


Question:   1) From whom will the SPBM receive the medical claims data post goes-live?

Answer:   It is anticipated that medical claims data would provided through the OMES System Integrator.

Date: 8/12/2020

Inquiry: 77921


Question:   Supplement One, Finance Management Requirements. What is number of staff the current contractor employs to maintain the finance management business functions?

Answer:   There is no incumbent for this procurement.

Date: 8/12/2020

Inquiry: 77920


Question:   Claim Processing: SPBM-010.050.080- Can the State provide an example of when a pharmacy would submit a UB04 claim to a PBM?

Answer:   This requirement is for the ability to export claim data from the Contractor’s system in a human readable format and not for the handling of pharmacy-submitted data to the PBM (e.g., generating a paper claim form in support of subrogation). The examples of claim formats provided in the requirement text are options that may fulfill the requirement and should not establish either minimum or maximum expectations of formats or the data fields necessary to be exported and printed.

Date: 8/12/2020

Inquiry: 77919


Question:   Base RFP, 6.1. May a bidder meet the minimum mandatory requirement to be a licensed TPA through an intercompany agreement with its affiliate who is a licensed TPA in Ohio?

Answer:   Offerors must be third-party administrators as defined in ORC 5167.01 and meet the requirements to be an Administrator in accordance with Chapter 3959 of the Revised Code.

Date: 8/12/2020

Inquiry: 77917


Question:   The Contractor must notify the recipient when PA is denied. Will ODM provide the number of denied PAs on a monthly, quarterly or annual basis, please?

Answer:   Duplicate There were approximately 153,000 denied prior authorizations for managed care members during calendar year 2019.

Date: 8/12/2020

Inquiry: 77914


Question:   The Contractor must notify the recipient when PA is denied. Will ODM provide the number of denied PAs on a monthly, quarterly or annual basis, please?

Answer:   There were approximately 153,000 denied prior authorizations for managed care members during calendar year 2019.

Date: 8/12/2020

Inquiry: 77913


Question:   Can the Fraud Waste and Abuse position be a remote position?

Answer:   This individual should be located in Ohio per Section 2.2 of Supplement 1.

Date: 8/12/2020

Inquiry: 77912


Question:   How will TPL edits be received?

Answer:   The question is lacking enough detail for ODM to properly respond. ODM may, at its option, disregard any questions which do not appropriately reference an RFP provision or location within the RFP.

Date: 8/12/2020

Inquiry: 77911


Question:   When it comes to COB which scenario will a contractor be expected to use for Claims Processing?

Answer:   The question is lacking enough detail for ODM to properly respond. ODM may, at its option, disregard any questions which do not appropriately reference an RFP provision or location within the RFP.

Date: 8/12/2020

Inquiry: 77910


Question:   Please provide examples of when we would need to notify MCOs and individuals.

Answer:   The question is lacking enough detail for ODM to properly respond. ODM may, at its option, disregard any questions which do not appropriately reference an RFP provision or location within the RFP.

Date: 8/12/2020

Inquiry: 77909


Question:   What type of financial correspondence would we need to provide MCOs and individuals?

Answer:   The question is lacking enough detail for ODM to properly respond. ODM may, at its option, disregard any questions which do not appropriately reference an RFP provision or location within the RFP.

Date: 8/12/2020

Inquiry: 77908


Question:   Scope of Work SPBM-030.010.040. The Contractor’s solution must capture and maintain MCO financial participation in payments to providers enrolled with ODM. The Contractor must make details of the MCO financial transactions available to ODM upon request. Question: Are MCO claims expected to be in separate checkwrite streams? Or on the same checkwrite but reported separately when required? How are MCO claims identified vs non-MCO?

Answer:   Duplicate

Date: 8/12/2020

Inquiry: 77906


Question:   Scope of Work SPBM-030.010.040. The Contractor’s solution must capture and maintain MCO financial participation in payments to providers enrolled with ODM. The Contractor must make details of the MCO financial transactions available to ODM upon request. Question: Are MCO claims expected to be in separate checkwrite streams? Or on the same checkwrite but reported separately when required? How are MCO claims identified vs non-MCO?

Answer:   MCO financial participation in payments would be for services not included in pharmacy claims. These would be payments for other services, such as quality improvement initiatives, that would be contracted by the MCO and paid to the participating pharmacies. The cost of these services will not be reimbursed by ODM to the SPBM, therefore needs to be financially accounted for separately.

Date: 8/12/2020

Inquiry: 77905


Question:   Scope of Work SPBM-030.010.010. The Contractor’s solution must have functionality to capture, process, and make payments for all payables associated pharmacy services for enrolled members, for all supported programs. Question: What will be the estimated volume of payments? What estimated percent of those payments are EFT vs check? Is the expectation that one bank account be utilized for all checkwrite stream(s)?

Answer:   Duplicate

Date: 8/12/2020

Inquiry: 77904


Question:   Scope of Work SPBM-030.010.010. The Contractor’s solution must have functionality to capture, process, and make payments for all payables associated pharmacy services for enrolled members, for all supported programs. Question: What will be the estimated volume of payments? What estimated percent of those payments are EFT vs check? Is the expectation that one bank account be utilized for all checkwrite stream(s)?

Answer:   Volume of payments will be determined by the offeror's solution for processing an annual estimate of 45 million claims for managed care members, and 4.5 million for fee for service members. ODM currently issues 75 - 80% of fee for service pharmacy payments using EFT. ODM does not have specific requirements for one bank account for all payments and offerors should propose what is needed for efficient operations and adequate financial controls.

Date: 8/12/2020

Inquiry: 77903


Question:   RFP Base, Section 3.4 Proposal Submittal. The RFP indicates that the offeror must provide a signed statement that the offerors proposal submitted in response to this RFP will be binding for 180 days from the proposal due date. Where in the offerors proposal should this signed statement be included?

Answer:   Duplicate

Date: 8/12/2020

Inquiry: 77902


Question:   RFP Base, Section 3.4 Proposal Submittal. The RFP indicates that the offeror must provide a signed statement that the offerors proposal submitted in response to this RFP will be binding for 180 days from the proposal due date. Where in the offerors proposal should this signed statement be included?

Answer:   Provide a statement [signed by an authorized signatory legally binding the Offeror] indicating that the Offeror’s proposal submitted in response to this RFP will be binding for 180 days from the proposal due date with the Cost Proposal package.

Date: 8/12/2020

Inquiry: 77901


Question:   Scope of Work Requirement SPBM-020.040.220. The PA transaction for which Contractor is responsible includes: rendering PA determinations resolving enrollee and provider grievances and appeals resolving provider requests for Contractor reconsideration of adverse PA decisions and issuing PA decision notices, whether the PA is approved, partially-approved, or denied, both to the requesting provider and to the enrollee on whose behalf the PA was sought. Will ODM provide an approximate number of appeals and grievance filed during the past year?

Answer:   ODM is not providing appeals and grievance volumes estimates. Offerors are encouraged to investigate industry standards to model appeals and grievance volumes.

Date: 8/12/2020

Inquiry: 77900


Question:   Base RFP, 4.11 Financial Capability. In the event ODM requests audited financial statements of the Offeror, will ODM accept the Offerors ultimate parent’s audited financial statements?

Answer:   Duplicate

Date: 8/12/2020

Inquiry: 77899


Question:   Base RFP, 4.11 Financial Capability. In the event ODM requests audited financial statements of the Offeror, will ODM accept the Offerors ultimate parent’s audited financial statements?

Answer:   Offerors must provide their audited financial statement. Offerors may provide ultimate parent's audited financial statements in addition to their own.

Date: 8/12/2020

Inquiry: 77898


Question:   RFP Base, Section 6.3, Attachment 3: Requirements for Proposal. Question: Follow-up question to inquiry #77863. The RFP indicates that the proposal must include tabbed sections. The list of sections includes: -- Response to Supplement Six -- Response to Supplement Seven In light of the response to Inquiry 77863 that indicates that there are no specific responses to Supplements Six and Seven, are these tabbed sections required to be included in bidders’ proposals? Are bidders required to submit these two supplements as part of their proposals?

Answer:   There is no requirement to include tabs for Supplements 6 and 7.

Date: 8/12/2020

Inquiry: 77897


Question:   Does the estimated production implementation date of December 11, 2021 apply to both the managed care and FFS programs? Or is it expected that the FFS program will be fully implemented at a later date?

Answer:   It is anticipated that the SPBM will assume responsibilities for fee-for-service (FFS) pharmacy benefits in the second year of the Contract.

Date: 8/12/2020

Inquiry: 77894


Question:   Please clarify or provide an example of what is meant by visualization documentation in requirement SPBM-180.110.020 - The Contractor must update the data visualization documentation within two (2) business days of approval by ODM.

Answer:   The data visualization documentation provided by the contractor is a description of the processes used to generate the data.

Date: 8/7/2020

Inquiry: 77889


Question:   Please define or provide example of business performance reports listed in requirement OMES-180.010.010-The Contractor’s solution must provide periodic business performance reports as defined by ODM.

Answer:   Business performance reports must be provided to support monitoring of Ongoing Performance Standards and Key Performance Indicators (Template B - Terms and Conditions, Sections 4.2 and 4.3).

Date: 8/7/2020

Inquiry: 77888


Question:   Please provide clarification or example on other OMES components for requirement OMES-180.000.060-The Contractor’s solution must provide the capability to produce reports and data extracts necessary to support the business functions and processes provided by other OMES components.

Answer:   The OMES has multiple forms of transmitting and receiving data and reporting. The primary means are through the System Integrator using webservices in a publish and subscribe model, batch file transfer via SFTP, and EDI transactions. The offeror is expected to support all defined communications protocols.

Date: 8/7/2020

Inquiry: 77887


Question:   Please provide clarification on requirement SPBM-020.020.010 - The Contractor must be able to implement various pharmacy value-based payment incentives to pharmacies as directed by ODM meant to improve outcomes such as differential provider payments and kick payments. Please clarify what types of outcomes and kick payments ODM is expecting. Please define kick payment.

Answer:   It is ODM's expectation that the vendor be able to pay individual pharmacy providers different fees, based on ODM-defined value incentives.  Kick payments are separate, one time payments to individual pharmacy providers in amounts and circumstances defined by ODM.

Date: 8/7/2020

Inquiry: 77886


Question:   Is it the States expectation to run the solution themselves as a Software as a Service or is it the States expectation for the bidder to run the solution but give access to authorized users as needed.

Answer:   It is ODM's expectation for the offeror to run the solution and give access to ODM authorized users as needed. For the purposes of this RFP, the offeror is expected to manage day to day activities as well as the system design, configuration, build, implementation, and ongoing support and maintenance

Date: 8/7/2020

Inquiry: 77879


Question:   Supplement 1 - Scope of Work - Page 61 In order to properly plan for call center staffing, can you provide the call volume for member and pharmacy help desk (separately)?

Answer:   ODM is unable to provide call volumes for the member and pharmacy help desk. Offerors are encouraged to investigate industry standards to model call volumes.

Date: 8/7/2020

Inquiry: 77864


Question:   Supplements 6 and 7 Please confirm how bidders should respond to Supplements 6 and 7.

Answer:   There are no specific responses required for Supplements 6 and 7. Refer to Supplement 1 for responses to requirements regarding Supplements 6 and 7.

Date: 8/3/2020

Inquiry: 77863


Question:   Is the State requesting confirmation of the requirements within documents Supplement 6 and Supplement 7 or written responses for each requirement?

Answer:   There are no specific responses required for Supplements 6 and 7. Refer to Supplement 1 for responses to requirements regarding Supplements 6 and 7.

Date: 8/3/2020

Inquiry: 77873


Question:   Can the state verify the contract start state and implementation period? Is the contract start date February 1, 2022, or February 2, 2021? Is implementation start date March 16,2021, and expected end date December 11, 2021?

Answer:   The estimated contract start date of the contract is February 1, 2021, the estimated implementation start date is March 16, 2021 and the estimated production implementation date is December 11, 2021.

Date: 8/3/2020

Inquiry: 77870


Question:   Supplements 2 and 5 Please confirm that no response is required for Supplements 2 and 5.

Answer:   There are no specific responses required for Supplements 2 and 5.

Date: 7/31/2020

Inquiry: 77862


Question:   Section 6.3 (page 44) The sections on page 44 for Supplement Three and Four mention a redaction process that is described in the RFP section entitled "Proposal Submittal" (3.5). Please provide information on that process.

Answer:   No redactions are permitted in accordance with Section 3.6.

Date: 7/31/2020

Inquiry: 77861


Question:   Section 6.1 (page 28), Section 6.3 Table 5 (page 42), Attachment 4 (page 46), and Attachment 5 (page 73) Section 6.1 mentions that bidders should provide exceptions to Attachment 4. Please confirm what format those should be provided in, and where in the proposal submission they should be included, as Attachment 4 is not mentioned in Section 6.3-Table 5. Please also confirm if bidders should provide exceptions to Attachment 5, in what form, and where this should be included in the proposal.

Answer:   All exceptions are to be provided in Template B. Section 8. in accordance with the instructions provided in Template B.

Date: 7/31/2020

Inquiry: 77860


Question:   Would ODM allow adding an additional column to the tables in sections 4, 5, 6, and 7 of the SPBM Supplement 1 - Scope of Work document in order to provide a Narrative response?

Answer:   Do not add any additional columns. Narrative responses are to be added at the end of each section.

Date: 7/31/2020

Inquiry: 77859


Question:   Will the State provide a claims data file for PBMs to use in modeling our offer?

Answer:   ODM does not intend to provide historical claims data to potential offerors.

Date: 7/30/2020

Inquiry: 77847


Question:   Given the restrictions still in place with COVID-19, including offices still under closure mandates, would ODM consider an email submission?

Answer:   ODM is currently equipped to receive mail and deliveries. Email submissions are not permitted for this project.

Date: 7/30/2020

Inquiry: 77836


Question:   Given the restrictions still in place with COVID-19, including offices still under closure mandates, would ODM consider an electronic submission?

Answer:   ODM is currently equipped to receive mail and deliveries. Email submissions are not permitted for this project.

Date: 7/30/2020

Inquiry: 77835


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Inquiry period ended:  8/24/2020 8:00:00 AM