Common use of Data and Systems Clause in Contracts

Data and Systems. 1. Contractor will not modify any operational or clinical program or process that substantially impacts the services Contractor provides to County during the Term of this Contract without the prior notification and approval of the County. 2. Contractor shall accept electronic data transfer and administer membership information in compliance with HIPAA standards for privacy, security and electronic data interchange. 3. Contractor shall agree to make internal practices, books, and records relating to the use and disclosure of PHI received from, or created or received by organization available to the Secretary of the Department of Health and Human Services for purposes of the Secretary of the Department of Health and Human Services determining organization's compliance with the privacy rules. 4. Contractor will adopt and implement written confidentiality policies and procedures in accordance with applicable law to ensure the confidentiality of member information used for any purpose. 5. Contractor will agree not use or further disclose protected health information (PHI) other than as permitted or required by the Business Associate Agreement or as required by law. 6. Contractor agrees to use appropriate safeguards to prevent the unauthorized use or disclosure of the PHI. Contractor agrees to report to the plan sponsor any unauthorized use or disclosure of the PHI. 7. Contractor agrees to mitigate, to the extent practicable, any harmful effect that is known to Contractor of a use or disclosure of PHI by Contractor in violation of the requirements of the federal privacy rule. 8. Contractor agrees to provide access to PHI in a "designated record set" in order to meet the requirements under 45 CFR 164.524. 9. Contractor agrees to make any amendment(s) to PHI in a "designated record set" pursuant to 45 CFR 164.526. 10. Contractor agrees to document such disclosures of PHI and information related to such disclosures as would be required to respond to a request by an individual for an accounting of disclosures of PHI in accordance with 45 CFR 164.528. 11. The Contractor agrees to: a. implement administrative, physical, and technical safeguards that reasonably and appropriately protect the confidentiality, integrity, and availability of the electronic PHI that it creates, receives, maintains, or transmits, b. report to the plan sponsor any security incident (within the meaning of 45 CFR 164.304) of which Contractor becomes aware, and c. ensure that any Contractor employee or agent, including any subcontractor to whom it provides PHI received from, or created or received by the Contractor agrees to implement reasonable and appropriate safeguards to protect such PHI. 12. Contractor will be required to perform claims review and routine audit functions to detect and prevent misbilled claims and fraud at retail, mail and specialty pharmacy. 13. Contractor will adjudicate claims based on the County's plan design. 14. Contractor will have electronic coordination of benefits. 15. Contractor will be required to load eligibility within 48 hours of receipt. 16. Contractor shall provide on-line, unlimited eligibility updating and entry capabilities for authorized County staff. Subject to applicable laws, rules and regulations relating to privacy and confidentiality, Contractor shall provide County’s Benefits Administrator and the County’s TPA with on-line access to read County’s eligibility information. 17. Contractor shall conduct manual eligibility updates at no charge to the County. In the case of emergency eligibility Contractor shall provide access for the County’s TPA staff to make on-line eligibility updates on a same-day basis. 18. Contractor shall contact County’s Benefits Administrator and/or the County’s TPA for verification of eligibility of a participant that is shown as ineligible online in the event of participant escalation. 19. Contractor shall receive on a weekly basis, an eligibility file of eligible County participants from County’s PPO TPA in an existing format defined in a separate file layout. Contractor shall treat the eligibility file sent by County’s TPA as a Full File eligibility file. Upon receipt of file, Contractor shall load and determine if any discrepancy thresholds are triggered. If so, County or its designee will be notified of eligibility discrepancies. Contractor shall update the eligibility file within two working days of receipt of the clean eligibility file. Currently, the eligibility file is provided in HIPAA-compliant American National Standards Institute (ANSI) 834 format; however, County reserves the right to change it. Contractor shall be willing to accept ANSI 834 and flat file formats. 20. Contractor shall notify County or its designee, if the eligibility file is not received by the due date identified on the file schedule provided by the County’s TPA. 21. Contractor shall notify County or its designee prior to the eligibility update application, of any material errors or coding problems on the eligibility file that exceeds agreed upon thresholds. 22. Contractor shall provide two complete claim files to the County’s Employee Benefits Consultant and County’s TPA on a quarterly basis via File Transfer Protocol. Contractor shall provide, on a monthly basis, claims information to County for each billing period in the format agreed to by County and Contractor. The claims information shall be reported separately for each group identified during the initial implementation process or for other sub-groups that may be added during the Contract Term. 23. Contractor will be required to provide electronic data feeds as needed at no additional cost for up to six unique contractors. Each data feed could be unique in nature and would range from daily to quarterly transmission intervals. Electronic data feeds may include but are not limited to: at least weekly feeds to the County's medical TPA; routine feeds to wellness contractors; financial claims history to consultants; clinical data to health plans and/or TPA; etc. 24. Contractor shall work with County’s medical TPA to ensure that prescription drug paper claims are paid appropriately. If County chooses to continue having its TPA administer paper claims on an emergency basis, the Contractor shall share data as permitted by applicable laws, rules and regulations relating to privacy and confidentiality to ensure that prescriptions are not both paid under the pharmacy network and by County’s TPA through a paper claim. 25. If requested, the Contractor must agree to process paper claims according to the fee structure detailed in Attachment B. 26. Contractor shall notify the County immediately upon identification of system-related problems, programming problems or data transfer problems. The Contractor shall make every effort necessary to correct such problems within 48 hours regardless of the time or date in order to minimize any disruption to participants. 27. Contractor shall provide necessary data files to respond to government requests or respond to class action lawsuits without additional fees for the length of the Contract. Such services shall be provided at standard programmer bill rates as defined by the County after the Contract has termed. 28. Contractor shall provide Medicare Part D services, specifically providing support for the Retiree Drug Subsidy filing and related activities. 29. Contractor shall meet all current and future reporting requirements with the Centers for Medicare and Medicaid Services (CMS) for Medicare Modernization Act (MMA) Part D. Contractor shall remove Part B items (e.g., diabetic supplies) from the files to be sent to CMS for the subsidy. Contractor shall ensure that MMA support meets County’s compliance, audit, and other standards. 30. Contractor shall be responsible for administering Coordination of Benefits (COB) as applicable for electronically processed claims. At County’s option, the Contractor shall be responsible for administering COB and other functions and services in regards to Medicare Part D subsidy activity including the provision of cost reports and filing. 31. Contractor shall invoice the County for pharmacy claims no more frequently than weekly. Other fees shall be invoiced monthly. 32. Contractor shall process subrogate Medicaid claims according to the fee structure detailed in Attachment B. 33. In the event of a platform or name change, the Contractor will pay any charges associated with the creation and distribution of new member ID cards by the TPA.