12 8500 Medical Case Management Swif

STATEMENT OF WORK
MEDICAL CASE MANAGEMENT SERVICES
INVITATION FOR BID 6100066211
OVERVIEW. The Commonwealth of Pennsylvania, Department of Labor & Industry (L&I), on
behalf of the State Workers' Insurance Fund (SWIF) is issuing this Invitation to Bid (IFB) to
procure a contractor(s) with the experience, background and certifications to provide the services
at competitive prices throughout the Commonwealth while ensuring that agency requirements
are met in compliance with the Pennsylvania Workers' Compensation Act, ("the Act"), 77 P.S.
1 et seq. and the Rules And Regulations, specifically Title 34 Pa Code Sections 123.201 -
123.302, and Pennsylvania case law which allow Pennsylvania workers' compensation insurers
to maintain or provide Field Based Medical Management on Workers' Compensation claims.
The awarded contractor(s) shall provide labor, materials, services, skills, supervision, and
necessary equipment to manage and Field Based Medical Management Services under this
contract. These services will be provided by the awarded contractor(s) as independent
contractor(s), not as an employee of the Commonwealth. The awarded contractor(s) shall render
services in accordance with the policies, procedures, and standards of the Commonwealth.
AWARD. A contract shall be awarded to all bidders determined to be responsive and
responsible. Bidders shall only bid on the territory or territories that they can effectively service.
Awarded Bidders will be reviewed on their ability to perform all the necessary services within
the territory bid.
If a bidder elects to bid all territories, bidder must have the ability to service the entire State.
Offerors shall select any or all the outlined territories. Any selected territories must be serviced
entirely.
The State Workers Insurance Fund (SWIF) estimates a total of 8,000 hours of Field Based
Medical Management in Territory A, 4000 hours of Field Based Medical Management in
Territory B; and 8000 hours of Field Based Medical Management in Territory C. Please note,
these are yearly estimates only and do not represent any guarantee of work. See Exhibit A for
geographical territory/territories
TERM. The term of contract shall commence on the start date and shall expire in three years,
with two single-year renewal options, unless it is terminated earlier pursuant to the terms of this
agreement. In the event the Commonwealth exercises any extensions against the contract, the
extension period shall be under the same contract terms and conditions.
There will be no purchase orders resulting from this contract. Work shall commence on the start
date identified on the Notice to Proceed (NTP).

QUALIFICATIONS. Interested qualified bidders must have a minimum of five (5) years of
experience providing Field Based Medical Management Services for workers' compensation
claims in Pennsylvania and possess Utilization Review Accreditation Commission (URAC)
accreditation in medical case management.
Bidders shall have a complete and thorough knowledge of PA Workers' Compensation Law as it
pertains to providing Field Based Medical Management on Workers' Compensation claims.
Personnel Assignment Requirements. The awarded bidders shall assign personnel who are
Registered Nurses (RNs) licensed by the Commonwealth of Pennsylvania Department of State
with experience in managing Workers' Compensation claims
RN Case Managers must be physically located in the geographical territory/territories in which
the services are provided as outlined herein.
WORKERS' COMPENSATION MEDICARE SET-ASIDE. In order to comply with 42
U.S.C. 1395y(b)(2) and 1862(b)(2)(A)(ii) of the Social Security Act, Medicare may not pay
for a beneficiary's medical expenses when payment "has been made or can reasonably be
expected to be made under a workers' compensation plan, an automobile or liability insurance
policy or plan (including a self-insured plan), or under no-fault insurance." Medicare must
always be secondary if another payment source is primary. If settling both the indemnity and
medical portions of a workers' compensation claim where the claimant is a Medicare beneficiary,
or may become a beneficiary, a Workers' Compensation Medicare Set-Aside (WCMSA) may be
done. A WCMSA provides an allocation or projected future lifetime projection for all future
work-injury-related medical expenses reimbursable by Medicare, to ensure that Medicare's
interests are protected.
WORK ASSIGNMENTS. Prior to placing an RN in an assignment, the awarded bidder shall
provide SWIF resumes, including all pertinent professional certifications, and background
checks for all personnel who will be working on this project, along with proof that such
personnel are employees of the bidder. Provide copies of all applicable certifications and license
personnel has including driver's license. (At a minimum, all case managers should be RNs or
Certified Case Manager's (CCMs)). SWIF reserves the right to accept or reject any candidate
considered for work.
Notice of personnel changes (addition or deletions) must be communicated to SWIF
immediately. In the case of deletions, the normal workload must be handled on a timely basis
until replacements are hired and assigned to the project. The Offeror shall immediately notify the
Department of Labor and Industry's (DLI) Issuing Officer and SWIF if any of its personnel are
accused of any inappropriate or criminal behavior related to the duties specified in this IFB. The

Offeror shall also notify the DLI and SWIF of any criminal prosecutions commenced against the
Offeror or its personnel within ten (10) calendar days of charges being filed.
SUBCONTRACTING.
The selected Offeror is prohibited from subcontracting or outsourcing any part of this Project
without the express written approval from the Commonwealth. Positions which can be
subcontracted can be for clerical support, billing, scheduling or other administrative functions.
Note: Offerors may not utilize RN subcontractors to provide Field Based Medical Management
services. RNs assigned by the Offeror to provide these services must be employees of the
Offeror.
REQUIREMENTS. The Offeror will provide Field Based Medical Management services on
those files referred to by SWIF, including catastrophic claims, based on the following:
a. Upon referral from SWIF, the Offeror will contact the claimant and his/her attorney
within forty-eight (48) hours of receipt of assignment. The RN shall provide the
appropriate SWIF District Office and Home Office with an initial report within thirty (30)
days of referral outlining the claimant's current medical status. Initial referrals for Field
Based Medical Management will be for a period as determined by SWIF. Extensions
must be approved by SWIF for each assignment.
b. The RN at SWIF's direction will meet at the appropriate SWIF office or hold
discussions by phone. The RN shall assess the medical and rehabilitation needs of the
claimant and coordinate appropriate medical care and establish a working relationship
with the designated SWIF Claim adjuster(s). It is understood that the RN may be required
to help in the preparation of and present testimony at hearings and depositions on referred
files as directed by SWIF.
c. File reviews with the Offeror will be held every thirty (30) days or any other time as
determined by SWIF. These reviews will be held at SWIF's direction, at the appropriate
SWIF Office or by phone discussion.
d. In the case of a catastrophic injury as determined by SWIF, the Offeror will visit the
claimant, in person, within twenty-four (24) hours of the date of said referral and submit
within seven (7) days thereafter a report to the SWIF District Office, with copies to the
Home Office. The Medical Management nurse will make telephone contact with the
assigned SWIF nurse or the SWIF adjuster. This report will outline the claimant's current
medical status, including projected medical costs and methods to be used to control same.
Thereafter, reports and itemized bills will be sent every thirty (30) days as required
herein.
e. Reports or records required by the Offeror shall be obtained by the Offeror with proper
approval of SWIF. The costs incurred by the Offeror in obtaining same shall be
reimbursed by SWIF, if receipts for the information accompany the invoice submitted for

services rendered. Independent Medical Examinations (IMEs) as authorized will be paid
for by SWIF
f. Home Modifications/Need for Durable Medical Equipment. Upon referral from SWIF,
the Offeror will be required to visit the injured workers' home to assess the need for
home modification(s). If SWIF agrees with the home modification assessment, the
Offeror will secure three (3) bids for the specific work to be performed and forward to the
SWIF District Office and Home Office. Any durable medical equipment needed will be
preapproved by SWIF and SWIF will determine whether the Offeror to be utilized for the
purchase or rental of the equipment
MONTHLY INVOICES AND REPORTS.
a. The Offeror shall submit computer-generated invoices monthly to the appropriate
SWIF District Office for services rendered on each file referred. The invoices shall list
the SWIF claim number, the claimant's name, the date of services and the Service
Provider's Federal Identification Number/Social Security Number. The invoices must
include a breakdown of charges, and a detailed report of the work performed.
b. The Offeror will also provide, in a format determined by SWIF, with a monthly activity
report listing the services provided for the period. In addition to the above, bidders will
be responsible for submitting status reports on each file referred to within fifteen (15)
days of the assignment. Subsequent status reports are due at thirty (30), sixty (60) and
ninety (90) day intervals from the assignment date. Reports will be reviewed by SWIF
management and the Offeror monthly.
TRAVEL. Travel Expenses: The Commonwealth requires the selected Offeror to provide
resources to meet the needs of the agencies at various locations (i.e. assigned work location)
throughout the Commonwealth without the need for significant travel on the part of the resource.
The Commonwealth will not reimburse the selected Offeror for travel, meals, lodging or other
expenses except when the Commonwealth requires a resource to travel outside of his or her
assigned location (i.e. assigned work location). Travel expenses will be reimbursed in accordance
with the Commonwealth Travel Policy SWIF will reimburse mileage for this contract. Mileage
starts from the shortest distance from your origination point (SWIF Office, Offeror's Office or
RN's home) directly to the SWIF Field Based Medical Management site and returning to the
SWIF Office, Offeror's Office or any other location, wherever is closest to the SWIF Field Based
Medical Management site. Mileage will be paid at current GSA published rates for privately
owned vehicles. http://www.gsa.gov/portal/content/100715
SOW Acceptance & Acknowledgement

This SOW is acceptable. I (We) hereby acknowledge and confirm that I (We) have read this SOW
and accept and approve the scope of work and related terms. I (We) understand that if additional
work is required that by its nature was not known or determined at the time this SOW was
executed, a written change order describing the additional work and any related expenses is
required.
Submission of a solicitation response shall constitute the bidder's acknowledgement of and
agreement to the requirements of this Statement of Work. Completion and signature of this SOW
Acceptance & Acknowledgement is requested; however, failure to complete or sign this
acknowledgment, in and of itself, shall not preclude consideration of an otherwise responsive
and responsible bid.
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Supplier/VENDOR Company Name
Approved & Acknowledged (date): _________________________
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Authorized Supplier Signature
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Authorized Supplier Printed Name Title