The vendor is required to provide the services, staff, and do all things necessary for or incidental to the performance of work, as set forth below:
• Bidder will attend a meeting on or around august 1, 2025.
• Authority discretion this meeting may take place remotely via virtual meeting platform.
• Provide all equipment necessary to perform the work outlined within this:
o Authority owned computer equipment for use by the contractor and its subcontractors to perform the work
o Provide bidder with authority owned computer equipment for use provided that the bidder’s request is approved by the dental program manager and authority enterprise technology services.
• Within five (5) business days of receipt from authority staff:
review initial client orthodontia service prior to authorization requests and supporting material, such as photographs, x-rays, case studies, and study models.
o Evaluate whether each initial client orthodontia service prior to authorization request meets the standard for being medically necessary based on criteria referenced
o Via the bidder’s access to provider one, document the clinical decision to approve, deny, reject or pend for each initial orthodontia services prior authorization request.
• Upon notification of receipt of additional information submitted to support a pended prior authorization (pa).
• If necessary, and as requested by authority, review grievances files by clients regarding the quality of care provided by enrolled orthodontia providers:
o Review each grievance and supporting material.
o Written recommendation to authority staff as to the relative merit of each grievance.
• If necessary, and as requested by authority, perform peer-to-peer contact:
o Train providers regarding completion of HLD scoring index.
o Discuss complicated client submittals.
o Discuss decision making process.
• Post orthodontic treatment records:
o Review post orthodontic treatment records and any supporting materials such as photographs, x-rays, case studies, and study models
o Evaluate whether orthodontic services provided and paid by authority meet the prevailing standards of care.
o A written recommendation to authority staff stating whether the orthodontic services provided and paid for by authority met the prevailing standards of care.
• New orthodontic treatments, techniques, modalities, or services:
o Review based upon evidence-based dental principles within the timeframe as requested by authority staff.
o Evaluate appropriateness for clients.
• Program policies, procedures, billing instructions, numbered memoranda, bulletins, proposed forms, proposed new or amended regulations, medical determination, or authorization criteria:
o Review as requested by authority against criteria and standards as provided by authority staff.
o Submit recommendation to authority staff.
• Meeting attendance is required either in person or virtual meeting platform on the following schedule:
o Monthly meetings at the outset of the program will be mutually agreed upon between authority and all contractors; and
o At authority sole discretion, the meeting schedule will be altered to meeting quarterly, instead of monthly
• Fair hearing attendance is required according to the following criteria:
o As requested by authority staff; and
o As bidder’s work schedule and availability permits.
• Communications regarding work done under this contract must be directed to the authority contract manager.
• Work hours and availability:
o Collaborate with the authority dental program manager to develop a work schedule.
o Proactively communicates changes in work schedule to the authority dental program manager including but not limited to vacations and out of the office.
o Check work emails every day the bidder is scheduled to work.
o Review and manage outlook calendar to ensure that you are attending meetings and fair hearings.
o Comply with authority administrative rules and provider guidelines regarding coverage and determining medical necessity.
• Provide best value and high-quality services, the bidder and authority agree to collaborate to improve processes and reporting through the term of the contract.
• Establish a profile for the contract and any subcontractor(s) giving access to the provider one system for the purpose of reviewing pa requests and recording recommendations for clinical decisions.
• Orient the bidder and any subcontractor(s) to provider one and NEA
• Provide bidder and any subcontractor(s) with VPN access and support to accomplish tasks
• Provide up-to-date online manuals, tutorials, and reference links.
• Provide calibration workshops on an as needed basis, as determined by authority.
- Contract Period/Term: 2 years
- Not-Mandatory Pre-Bid Conference Date: April 30, 2025
- Questions/Inquires Deadline: May 6, 2025