SECTION C

DESCRIPTION/SPECIFICATIONS
PERFORMANCE STATEMENT OF WORK

C.1 INTRODUCTION

Peace Corps is an independent executive agency of the Federal Government established in 1961 by
President John F. Kennedy to promote world peace and friendship through the service of American
volunteers abroad. The volunteers’ service fulfills the three primary Peace Corps goals established
in the founding legislation: 1) Improve the lives of people through grassroots assistance, 2) Foster
a better understanding of Americans on the part of the people served, and 3) Foster a better
understanding of other people on the part of Americans. The agency currently manages more than
7,700 volunteers in approximately 70 international posts.

Peace Corps manages healthcare services for more than 15,000 individuals each year. These
individuals are Applicants, Peace Corps Volunteers (PCVs), and Returned Peace Corps Volunteers
(RPCVs). The health benefits program is comprised of both a self-insured and a fully insured
component.

Applicants for Peace Corps service receive medical, dental, and vision examinations used by
VS/MS to evaluate health status. Applicants to the Peace Corps are not “reimbursed” for medical,
dental, or vision screening expenses; however, cost-sharing financial assistance is administered
based on pre-determined eligibility and proof of out-of-pocket cost. Cost-sharing maximum
allowances are based on basic medical screening requirements for various patient populations.
Services related to Applicants are referred to as benefit PLAN I.

While overseas, PCVs receive routine and emergency medical care, preventive health services, and
health promotion from health care professionals at Peace Corps posts. In addition, PCVs receive
care from international healthcare providers such as but not limited to doctors, counselors, dentists,
and other medical specialists who may be identified, vetted, and compensated via the services
provided under this contract. Some beneficiaries may receive care in the US while on authorized
leave or due to medical leave, aka medical hold. Some care may include emergency air ambulance
transportation. Services related to PCVs are referred to as benefit PLAN II.

Upon completion of service, RPCVs are entitled to extend health insurance coverage for up to 18
months and may be eligible for Federal Employee Compensation Act (FECA) benefits under
Department of Labor (DOL) regulations if they meet required criteria. RPCVs may also be
authorized by the Peace Corps for treatment or other healthcare up to six months after the
completion of their volunteer service, which is not FECA related. Services related to RPCVs are
referred to as benefit PLAN III.

Peace Corps’ Volunteer health system is administered by its Office of Volunteer Support - Medical
Services (VS/MS), which is located at 1111 20th Street, NW, 5th Floor, Washington, D.C. 20526.

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Peace Corps Medical Support Background Information:

PLAN I
Peace Corps applicants submit their medical receipts after paying out-of-pocket or in accordance
with their individual insurance, for exams required to be cleared for entry into the Peace Corps.
Following the submission of payment receipts, cost-sharing financial assistance is administered
and provided directly to the beneficiary. The maximum amount of cost-sharing is based on an age
and gender formula that corresponds to basic medical screening requirements.

PLAN II
When in the US on leave status, PCVs who require routine medical or dental care receive health
care services from US providers whose costs are paid for by Peace Corps through a self-insured
health benefits program. All healthcare services provided to beneficiaries must be pre-authorized
by Peace Corps and are reimbursed to the beneficiary or paid to the provider in accordance with
Peace Corps Health Benefits Program fee schedule.

PCVs overseas who require non-routine or emergency medical, mental health, or dental evaluation
and treatment may be medically evacuated aka "med-evaced" to the US or to regional locations
worldwide. Some PCVs may require emergency air ambulance transportation as a matter of course
in their healthcare. Washington, D.C. is the most common US med-evac site but the PCV’s home
of record is used as well.

PLAN III
RPCVs who require post-service evaluation may receive services from local providers. Pre-
authorized services are generally provided in the US, but may be provided overseas. Payments
made for evaluations provided to eligible claimants are reimbursed by Peace Corps.

RPCVs that require post-service treatment for health conditions stemming from or exacerbated by
overseas service are entitled to petition for relief under FECA. Conditions with onset during Peace
Corps service, which are service-connected, as well as pre-existing conditions aggravated,
accelerated or precipitated by service are covered under FECA. For the purpose of FECA benefit
eligibility, all PCVs are considered "employed" 24 hours a day, 7 days per week, while outside the
United States. All service-related conditions, with or without associated disability, are eligible for
FECA benefits through the US DOL. FECA benefits are separate from and in addition to benefits
provided by a fully insured program for those conditions not related to Peace Corps service.

C.2 SCOPE

The scope of this contract is to provide services to Peace Corps in the support and administration
of the self–insured component of its Health Benefits Program including air ambulance
transportation services. The award made by the Peace Corps to the Contractor(s) will be either for
the health benefits specific components only, C.4 – C. 7, or for the air ambulance component only,
C.8, or for both as described in C.4 – C.8. Service by the Contractor shall include:
Peace Corps Self-insured Component for PCVs, RPCVs [and Their Dependents]

1. Applicant Cost-Sharing Component

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The Contractor shall manage and administer PLAN I for Applicants to Peace Corps service.

2. Provider Network Component

The Contractor shall:

a. Provide access to a network of credentialed hospitals, qualified physicians, ancillary service

providers, mental health professionals, dentists, and diagnostic and treatment facilities with the
capacity to meet the healthcare needs of PCVs med-evaced to the Washington, D.C. metro area
and to provide professional consultation for Peace Corps medical staff. This network will
herein be referred to as the Washington, D.C. Service Network.

b. Provide access to a national Preferred Provider Network (PPO) of credentialed hospitals,

physicians, ancillary service providers, mental health professionals, dentists, and diagnostic
and treatment facilities with the capacity to meet the healthcare needs of PCVs and RPCVs in
the United States for medical evacuation to home-of-record, medical hold, home leave or
administrative leave. This does include coverage for the PCV while in travel mode between or
among domestic and international.

c. Provide access to an international Preferred Provider Network (PPO) of credentialed

hospitals, physicians, ancillary service providers, mental health professionals, dentists, and
diagnostic and treatment facilities with the capacity to meet the healthcare needs of PCVs and
RPCVs working overseas, when requested.

d. Provide access to emergency evacuation services such as air ambulance transportation; This
may include air ambulance services at international locations and in conjunction with various
international healthcare facilities.

e. Provide access to Preferred Provider Network (PPO) of physicians, laboratories and

ancillary service providers for applicants to Peace Corps when requested.

3. Pharmaceutical Component

The Contractor shall:

Provide access to a managed prescription drug service for use by PCVs while they are in the
US on medical hold or authorized leave.

4. Claims Component

The Contractor shall:

a. Support the administrative and financial management of and provide claims

processing and reimbursement and payment services for Peace Corps’ Health Benefits
Program; and

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 b. Provide claims re-pricing and discount services for the national PPO and
international PPO.

c. Inform home of record (HOR) providers participating in the national PPO of the
health benefits program in advance of claims processing with an informational document
and/or direct customer service;

d. Provide a contact or representative for interaction with HOR providers who have
questions on the processing of any health benefit claim;

e. Prepare, orient, and inform beneficiaries of the health benefits program in advance
of claims processing with an informational document and/or direct customer service;

f. Provide a contact or representative for applicants, Volunteers and Returned

Volunteers who have questions on the processing of any cost-sharing or health benefit
claim;

g. Follow-up with beneficiaries and/or providers regarding unpaid claims and resolve
questions, delays, or procedural errors on the part of beneficiaries and/or providers.

5. Air Ambulance Component (Preferred; optional award, see Section B of the RFP)

The Contractor shall provide worldwide emergency evacuation services, to include:

a. Land and/or air medical evacuation from remote locations to appropriate medical treatment
facility;
b. Database of credentialed, accepting facilities to assist in appropriate destination selection
when requested to do so.
c. Trained medical personnel and medical equipment sufficient to maintain a critically ill
Volunteer in a stable mode from time of acceptance until transferred to receiving medical
treatment facility;
d. Medical management, relevant technology, case consultation, timely and accurately
communication; and
e. Medical confidentiality of all records in accordance with agency policy and federal
regulations.

C.3 GENERAL REQUIREMENTS OF THE CONTRACTOR

Peace Corps is especially committed to doing no harm, to acting in good faith, and to preserving its
reputation as an agent of goodwill in the eyes of beneficiaries of its Health Benefits Program and
of the American public. The Contractor, therefore, shall provide access to high quality,
responsive, timely healthcare and administrative services in a manner that preserves Peace Corps’
good working relationship with beneficiaries of its Health Benefits Program.

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The Contractor shall:

a) Provide satisfactory assurances that the Contractor and all affiliated contractors will maintain
and protect the confidentiality of “protected health information”, health insurance medical
records, documents, and claims received from the Peace Corps, as required by Health
Insurance Portability and Accountability Act (HIPPA).

b) Comply with, and require that all affiliated contractors comply with, the Health Information
Portability and Accountability Act (HIPAA) and the Privacy Act of 1974, (5 U.S.C. § 552a,
Public Law No. 93-579) for the duration of the performance period of this Contract.

c) Keep Peace Corps’ Contracting Officer Technical Representative (COTR) apprised of

incidents, situations, and circumstances that affect the administration, management, financial
viability or costs associated with its health insurance program on an ongoing basis,
recommending action to resolve those issues that require immediate intervention.

d) Attend meetings called by Peace Corps to investigate and/or resolve incidents, situations, and
circumstances that affect the administration, management, or costs associated with its Health
Benefits or Health Insurance Program.

e) Administer Peace Corps’ Health Benefits Program components in accordance with the policies
established by Peace Corps for each benefit PLAN.

f) Manage the accounts of Peace Corps’ Health Benefits Program on a Federal Government
Fiscal Year schedule beginning October 1st and ending the following September 30th.

g) Designate an account representative to serve as ongoing liaison to Peace Corps. This account
representative, or a designee duly authorized to act in the account representative's absence,
shall be available to handle inquiries made by Peace Corps’ personnel between the hours of
9:00 a.m. and 6:00 p.m. Eastern Time on established US Government workdays.

h) Maintain a current minimum financial strength rating of A- (excellent) as assigned by the A.M.
Best Company (A.M. Best) and/or Standard and Poor’s current minimum rating of AA (very
strong). Provide satisfactory assurances that the Contractor and all subcontractors, insurers,
claims and program administrators report on a regular basis and maintain acceptable financial
stability, required licensing and service ratings from rating organizations such as A. M. Best
and/or Standard and Poor’s.

i) No Contractor employees will be required to work on site.

j) No claims processing staff are subject to Peace Corps personnel security clearances.

k) The Contractor shall provide staff to adjudicate claims in 20 business days from the date the
claim is received by the Contractor.

l) The Contractor is not required to pay any interest payment on claims paid later than 20

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 business days.

m) Preferred length of record retention is 5 years beyond the close of the fiscal year in which the
claim was adjudicated.

C.4 APPLICANT COST-SHARING COMPONENT

C.4.1 Contract Requirements for Applicant Cost-Sharing Component

The Contractor shall:

Issue, track and manage the cost-sharing allowance to PLAN I beneficiaries.

C.4.2 Service Requirements for Applicant Cost-Sharing Component

The Contractor shall:

a) Receive and process cost-sharing claims within 20 business days of receipt;
b) Provide customer service to Applicants who inquire about the status of their cost-sharing
allowance;
c) Distribute the cost-sharing allowance to eligible Applicants.

C.4.3 Quality Assurance of Applicant Cost-Sharing Component

The Contractor shall create a quality assurance plan addressing timely and accurate Applicant cost-
share allowance processing and accountability reporting.

C.4.4 Procedures and Reports for Applicant Cost-Sharing Component

Procedures developed by the Contractor shall adhere to effective customer service for PLAN I
beneficiaries. Reports developed by the Contractor shall capture all financial status transactions
and processing for PLAN I beneficiaries, and for the overall plan.

C.4.4.1 Applicant Cost-Sharing Procedures

Peace Corps will identify cost-sharing allowance ceilings for PLAN I beneficiaries. The
Contractor shall follow such guidelines as delivered and develop thorough procedures for
customers. Peace Corps may cite exceptions and allow for cost-sharing or reimbursement above
and beyond the established ceiling for an individual or group.

C.4.4.2 Applicant Cost-Sharing Reports

The Contractor shall, on a monthly basis, report on the full status of the cost-sharing task. The
report may include names of beneficiaries who have submitted receipts, how much the receipts are
for each of (1) medical, (2) vision, and (3) dental expenses, who has received their cost-sharing
allowance, and who has not yet received their cost-sharing allowance. The report should
summarize all activity of benefit PLAN I, express the amount beneficiaries receive, and the status
of beneficiary actions.

C4.5 Applicant Cost-Sharing Records

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The Contractor shall maintain financial records for five years.

C4.5.1 Applicant Cost-Sharing Record of Complaints

The Contractor shall maintain a record of beneficiary complaints along with resolutions applied to
such complaints.

C.5 NETWORK PROVIDER COMPONENT

C.5.1 Contract Requirements of the Washington, D.C. Service Network

The Contractor shall provide access to a network of qualified physicians and ancillary service
providers, mental health professionals, dentists, and diagnostic and treatment facilities (the
“Washington, D.C. Service Network”) with the capacity to meet the healthcare needs of med-
evaced PLAN II PCVs and their minor dependents whose medical, mental, and/or dental
conditions have been evaluated and deemed beyond appropriate management in an overseas
environment and who are med-evaced under Peace Corps’ authority to the Washington, D.C. metro
area for evaluation and/or treatment. The Contractor shall provide access to medical and dental
service through 1) a single network that includes physicians and dentists or 2) separate medical and
dental provider networks.

The Contractor shall integrate current network providers (Georgetown University Hospital, George
Washington University Hospital, Sibley Hospital, Virginia Hospital Center, and Custom Panel
Providers with a network broker to maximize re-pricing opportunities on all out of network claims
submitted.
C.5.2 Service Requirements of the Washington, D.C. Service Network

The Contractor shall--

a) Ensure that practitioners and facilities affiliated with the Washington, D.C. Service Network
allow 24-hour phone access for the purposes of emergency inquiry and 24-hour access to
emergency evaluation and treatment facilities 365 days a year.

b) Establish and maintain mechanisms to ensure that in-network referrals for evaluation and
treatment are given priority attention by practitioners and facilities affiliated with the
Washington, D.C. Service Network. Priority attention is defined as services that occur or
commence within two business days of an in-network referral.

c) Facilitate timely communication and transmission of medical reports and records from
practitioners and facilities affiliated with the Washington, D.C. Service Network to Peace
Corps’ medical staff. Timely communication and transmission is defined as 1) a complete
response to a telephone inquiry or written report issued and mailed or faxed by the service
provider within 24 hours of an evaluation or treatment and 2) a written report issued and

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 mailed or faxed by the service provider within five business days of the end of a course of
evaluation and/or treatment.

d) Provide general practice and specialist physicians, mental health professionals, and dentists
who are qualified based on the required license, board-certification and credentials for their
respective areas of practice. They must also be in good professional standing to meet the health
needs of med-evaced PCVs and practice within a ten (10) mile radius of Peace Corps’
Washington, D.C. headquarters building at 1111 20th Street, NW.

e) Provide institutional care to meet the health needs of med-evaced PCVs at treatment facilities
that are accredited and/or Medicaid/Medicare certified and state licensed as appropriate and are
located within a ten (10) mile radius of Peace Corps’ Washington, D.C. headquarters building
at 1111 20th Street, NW.

f) Administer a procedure for credentialing physicians, mental health professionals, and dentists
affiliated with the Washington, D.C. Service Network. The re-credentialing of the
Washington, D.C. Service Network providers shall occur no less than once every three years.

g) Establish, administer, and facilitate a procedure that permits other qualified physicians, mental
health professionals, and dentists referred to the Washington, D.C. Service Network by Peace
Corps who agree to accept the fees and meet other requirements of the Washington, D.C.
Service Network to affiliate with the network. These providers will be known as the Open
Panel. Re-credentialing of Open Panel providers shall occur no less than once every three
years.

h) Administer a procedure for assuring that hospitals, diagnostic and treatment facilities affiliated
with the Washington, D.C. Service Network maintain appropriate accreditation and/or
certification. In the event that a facility within the Washington, D.C. Service Network loses its
accreditation, certification, and or state license, the Contractor shall give written notice to
Peace Corps within 24 hours of learning of the loss of accreditation or certification.

i) Assure that practitioners and facilities affiliated with the Washington, D.C. Service Network
and Open Panel accept payment for services made in accordance with Peace Corps’ Health
Benefits Program fee schedules as payment in full and that these practitioners and facilities
refrain from billing or otherwise attempting to collect any balance that exceeds authorized
payment or reimbursement amounts for services provided to PLAN II PCVs or PLAN III
RPCVs beneficiaries.

j) Inform the Washington, D.C. Service Network and Open Panel providers of Peace Corps’
service requirements and policies prior to contract implementation and do so again within
thirty days following any subsequent contract renewal or contract modification that affects
service requirements or operating procedures.

k) Should Peace Corps’ medical staff make a referral for service to an out-of-network provider,
the Contractor assure that staff and persons and facilities affiliated with the Washington, D.C.
Service Network and Open Panel cooperate with and do not impede the Peace Corps’ effort to

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 undertake the referral.

C.5.3 Contract Requirements for the National PPO

The Contractor shall provide access to a National PPO for services provided to all beneficiaries
with proper authorization. A National PPO shall operate in all 50 states in the US, and in Puerto
Rico.

The Contractor shall:

a) Assure access to the managed prescription drug services 24 hours a day, 365 days a year.

b) Provide Peace Corps with identification cards for the National PPO to be issued to eligible
beneficiaries to provide a mechanism that permits individual access to providers in the network
anywhere in the US including Alaska and Hawaii and in Puerto Rico.

c) Inform National PPO providers of Peace Corps’ service requirements and policies prior to
contract implementation and again within thirty days following any subsequent contract
renewal or contract modification that affects service requirements or operating procedures.

d) Ensure that the National PPO complies with HIPAA requirements, as applicable at all times
during the performance of this Contract and any Subcontracts to this Contract.

C.5.4 Service Requirements for the National PPO

The Contractor shall:

a) Provide general practice and specialist physicians, mental health professionals, and dentists
who are qualified based on the required license, board-certification and credentials for their
respective areas of practice. They must also be in good professional standing to meet the
health needs of PCVs and RPCVs.

b) Provide institutional care to meet the health needs of med-evaced PCVs at treatment
facilities that are accredited and/or Medicaid/Medicare certified and state licensed as
appropriate and are located throughout the United States and Puerto Rico.

c) Administer a procedure for credentialing physicians, mental health professionals, and

dentists affiliated with the National PPO. The re-credentialing of the National PPO
providers shall occur no less than once every three years.

d) Administer a procedure for assuring that hospitals, diagnostic and treatment facilities
affiliated with the National PPO maintain appropriate accreditation and/or certification. In
the event that a facility within the National PPO loses its accreditation, certification, and or
state license, the Contractor shall give written notice to Peace Corps within 24 hours of
learning of the loss of accreditation or certification.

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 e) Assure that practitioners and facilities affiliated with the National PPO accept payment for
services made in accordance with Peace Corps’ Health Benefits Program fee schedules as
payment in full and that these practitioners and facilities refrain from billing or otherwise
attempting to collect any balance that exceeds authorized payment or reimbursement
amounts for services provided to PLAN II PCVs or PLAN III RPCVs beneficiaries.

f) Inform the National PPO providers of Peace Corps’ service requirements and policies prior
to contract implementation and do so again within thirty days following any subsequent
contract renewal or contract modification that affects service requirements or operating
procedures.

g) Should Peace Corps’ medical staff make a referral for service to an out-of-network
provider, the Contractor assure that staff and persons and facilities affiliated with the
National PPO cooperate with and do not impede the Peace Corps’ effort to undertake the
referral.

C.5.5 Contract Requirements for International PPO

To provide access to a Preferred Provider Network (PPO) of hospitals, physicians, ancillary

service providers, mental health professionals, dentists, and diagnostic and treatment facilities with
the capacity to meet the healthcare needs of PCVs[, and their dependents,] and RPCVs[, and their
dependents,] internationally, when requested.

C.5.6 Service Requirements for the International PPO

The Contractor shall:

a) Provide a guarantee letter of payment upon request of the Peace Corps to providers at
international locations.

b) Establish, administer, and facilitate a procedure that permits other qualified physicians,
mental health professionals, and dentists referred to the Washington, D.C. Service
Network by Peace Corps who agree to accept the fees and meet other requirements of
the Washington, D.C. Service Network to affiliate with the network. These providers
will be known as the Open Panel. Re-credentialing of Open Panel providers shall occur
no less than once every three years.

c) Assure that practitioners and facilities affiliated with the National PPO accept payment
for services made in accordance with Peace Corps’ Health Benefits Program fee
schedules as payment in full and that these practitioners and facilities refrain from
billing or otherwise attempting to collect any balance that exceeds authorized payment
or reimbursement amounts for services provided to PLAN II PCVs or PLAN III
RPCVs beneficiaries.

C.5.7 Quality Assurance of the Network Provider Component

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The Contractor shall provide and maintain a quality assurance and improvement program, which
shall be approved by Peace Corps, 30 days after contract award. This program shall include, but
not be limited to, 1) a procedure for reviewing and resolving complaints regarding the Washington,
D.C. Service Network, and National PPO and 2) a procedure for terminating affiliation with
hospitals, physicians, ancillary service providers, mental health professionals, dentists, and
diagnostic and treatment facilities affiliated with the Washington, D.C. Service Network, and
National PPO. In the event that the Contractor terminates affiliation with practitioners or facilities
within the Washington, D.C. Service Network, the Contractor shall give written notice to Peace
Corps within 24 hours of terminating the affiliation. Such notice shall identify the Contractor’s
replacement affiliate/Subcontractor and any new benefits that exceed those stated in this Contract.
At no time shall the Contractor affiliate with a replacement provider for benefits that do not meet
or exceed the requirements in this contract.

C.5.8 Procedures and Reports of the Network Provider Component

C.5.8.1 Network Provider Procedures

Thirty days after contract award, the Contractor shall provide Peace Corps with 1 hard copy and
ongoing electronic access to an updated procedures manual that contains, but is not limited to:

a) the names of the Contractor's account representative and other key personnel, their phone and
fax numbers, and their mailing addresses;

b) a physical and electronic directory listing the members of the Washington, D.C. Service
Network and Open Panel providers, their specialties, their phone and fax numbers, and their
mailing addresses;

c) a description of routine and emergency procedures for accessing the Washington, D.C. Service
Network;

d) a description of routine and emergency procedures for accessing the National PPO Service
Network;

e) a description of the procedure for issuing identification cards to eligible beneficiaries of Peace
Corps’ Health Benefit Program;

f) a description of routine and emergency procedures that address identifying and accessing med-
evac resources including facilities and international PPO Network providers.

g) a description of the procedure for receiving, monitoring, and resolving complaints that may be
brought by Peace Corps to the Contractor's attention regarding Washington, D.C. Service
Network, the National PPO Network and Open Panel providers; and

h) a description of the Contractor's procedure for credentialing, for affiliating with, and for
terminating affiliation between practitioners and facilities affiliated with the Washington, D.C.

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 Service Network, the National PPO Network and the International PPO Network

C.5.8.2 Network Provider Reporting Requirements

a) The Contractor shall provide Peace Corps with access to an electronic data directory of the
Washington, D.C. Service Network, Open Panel providers, National PPO Network and shall
notify the COTR of changes as they occur.

b) Annually, the Contractor shall provide Peace Corps with credentialing, accreditation or
certification reports pertaining to the Washington, D.C. Service Network, the National PPO
Network, and the international PPO Network.

c) Quarterly, the Contractor shall provide to Peace Corps a quarterly activity report which must
include estimated cost savings and enhanced service levels of contract activities obtained
through the use of the Washington, DC Service Network, the National PPO Network, and the
international PPO Network, and claims re-pricing.

d) Quarterly, the Contractor shall provide to Peace Corps a summarized activity report of
comparative medical, mental health, and dental expenses assumed within the Washington, DC
Service Network and Open Panel providers.

e) Semi-Annually, the Contractor shall provide to Peace Corps a financial summary report of all
medical expenses organized to provide insight into resource utilization and quality
improvement through data-driven management.

f) Semi-Annually, the Contractor shall provide to Peace Corps a financial summary report of all
mental health expenses organized to provide insight into resource utilization and quality
improvement through data-driven management.

g) Semi-Annually, the Contractor shall provide to Peace Corps a financial summary report of all
dental expenses organized to provide insight into resource utilization and quality improvement
through data-driven management.

C.5.9 Network Provider Records

The Contractor shall maintain records of network providers and must be able to summarize
changes in credential or demographic status related to any individual provider.

C.5.9.1 Network Provider Record of Complaints

The Contractor shall maintain accurate and complete records of complaints regarding all of the
provider networks: the Washington, D.C. Service Network, National PPO Network, and
International PPO Network. “Complaints” are defined as verbal or written notices of
dissatisfaction with service providers. These records shall be made available to Peace Corps upon
the formal written request of the COTR and or the Contracting Officer.

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C.6 PHARMACEUTICAL COMPONENT

C.6.1 Contract Requirements of the Pharmaceutical Component

The Contractor shall provide access to a managed prescription drug service for use by PLAN II
PCVs who are med-evaced to the US or who are on authorized leave in the US.
C.6.2 Service Requirements of the Pharmaceutical Component

The Contractor shall designate an account representative to serve as ongoing liaison to Peace
Corps. This account representative, or a designee duly authorized to act in the account
representative's absence, shall be available to handle inquiries made by Peace Corps’ personnel
between the hours of 9:00 a.m. and 6:00 p.m. Eastern Time on established US government
workdays. In addition, the Contractor shall:

a) Assure access to the managed prescription drug services 24 hours a day, 365 days a year;

b) Provide the Peace Corps with identification cards to be issued to eligible beneficiaries of
managed prescription drug services;

c) Provide a mechanism that permits managed prescription drug providers to ascertain individual
eligibility for pharmaceutical services at point of service; and

d) Inform managed prescription drug service providers of Peace Corps’ service requirements and
policies prior to contract implementation and again within thirty days following any
subsequent contract renewal or contract modification that affects service requirements or
operating procedures.

C.6.3 Quality Assurance of the Pharmaceutical Component

The Contractor shall establish and maintain a quality assurance and improvement program, which
shall be approved by Peace Corps. This program shall include, but not be limited to appropriate
standards for and procedures for 1) monitoring and improving pharmaceutical claims made/paid
turnaround times; 2) monitoring and improving customer service response times; 3) monitoring
and reducing the rates of pharmaceutical claims denied; 4) monitoring and reducing financial and
non-financial error rates; 5) documenting and resolving customer service complaints.

C.6.4 Procedures and Reports of the Pharmaceutical Component

C.6.4.1 Pharmaceutical Component Procedures

Thirty days after contract Date of Award, the Contractor shall provide the Peace Corps with 1 hard
copy and ongoing electronic access to an updated procedures manual that contains, but is not
limited to:

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a) the names of the Pharmaceutical Contractor's account representative and other key personnel,
their phone and fax numbers, and their mailing addresses;

b) a description of the procedure for issuing identification cards to eligible beneficiaries of the
Peace Corps Health Benefits Program;

c) a description of the procedure for accessing the Pharmaceutical Contractor's managed

prescription drug service; and

d) a summary of benefits and access instructions suitable for distribution to the Peace Corps
Health Benefit Program members.

C.6.4.2 Pharmaceutical Component Reports

The Contractor shall provide to Peace Corps ongoing electronic access to a monthly drug
utilization report, beginning 30 days after contract Date of Award with monthly updates during the
contract period. The utilization report shall identify the names of drugs provided and the
therapeutic classification of those drugs ranked in order of 1) number of prescriptions filled and 2)
cost to Peace Corps. The report shall also summarize: 1) number of claims processed, 2) number
of claims denied, 3) number of claims paid, 4) number of paid single source brand claims, 5)
number of paid multi-source brand claims, 6) number of paid generic claims, 7) percent of generic
use, 8) percent of generic conversion, 9) savings from generic substitution, 10) number of generic
conversions missed, and 11) report claims trends.

Ninety days after the end of a fiscal year and every year thereafter during the term of the Contract,
the Contractor shall deliver one copy and provide electronic access of an annual drug utilization
report to Peace Corps.

C.6.5 Pharmaceutical Component Records

The Contractor shall maintain an accurate and complete claims record for each individual
beneficiary.

C.6.5.1 Pharmaceutical Component Record of Complaints

The Contractor shall maintain accurate and complete records of complaints regarding any or all
aspects of pharmaceutical services. “Complaints” are defined as verbal or written notices of
dissatisfaction with service providers. These records shall be made available to Peace Corps upon
the formal written request of the COTR and or the Contracting Officer.

C.7 CLAIMS COMPONENT

C.7.1 Contract Requirements of the Claims Component

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The Contractor shall accurately and promptly process, reimburse/pay, or deny in accordance with
Peace Corps’ Health Benefit Program policy all claims for authorized healthcare
submitted on behalf of eligible Peace Corps’ Health Benefits Program PLAN I
Applicants, PLAN II PCVs and their dependents, and PLAN III RPCVs and their
dependents.

The Contractor shall not charge a deductible fee nor charge a co-payment to any Peace Corps
Health Benefits Program participant. The Contractor shall not, however, assume any liability for
deductibles, co-payments, or bills for the balance between claims made and claims paid.

The Contractor shall, however, be held liable for reimbursement or payment of any fraudulent,
wasteful, or abusive claim, for reimbursement or payment of an unauthorized or unallowable claim
or of a payment or reimbursement made on behalf of an ineligible person.

The Contractor shall maintain copies of bills for a period of five years.
C.7.2 Service Requirements of the Claims Component

The Contractor shall designate an account representative among key personnel to serve as ongoing
liaison to Peace Corps. This account representative, or a designee duly authorized to act in the
account representative's absence, shall be available to handle inquiries made by Peace Corps
between the hours of 9:00 a.m. and 6:00 p.m. Eastern Time on established US Federal Government
workdays. The Contractor shall provide a message system to record inquiries made at all other
times. In addition, the Contractor shall:

a) Provide customer service agents sufficient to respond to inquiries regarding participant

eligibility, claims processing, fee schedules, and reimbursements/payments in a timely manner
consistent with commercial standards They shall be available for inquiry between the hours of
9:00 a.m. and 6:00 p.m. Eastern Time on established US Federal Government workdays. The
Contractor shall provide a message system to record inquiries made at all other times.
b) Provide claims processors to review and adjudicate Peace Corps’ Health Benefits
c) Provide toll-free telephone service to receive inquiries regarding eligibility, claims processing,
and reimbursements/payments.

d) Log all claims and supporting documentation received into the healthcare claims processing
system within 24 hours of receipt from beneficiary.
e) Adjudicate all claims for services provided in the US within 20 business days of receipt;
f) Provide letters of Guarantee Payment to international providers when requested to do so by the
Peace Corps.
g) Pay “clean” claims within 20 business days of receipt. For the purposes of this Contract, a
“clean” claim is defined as one submitted on behalf of an eligible PLAN participant for
authorized, allowable healthcare services that were provided in the US and are appropriately
documented; and
h) Adjudicate claims for services provided outside of the US within thirty business days of
receipt.

i) Administer timely procedures for reviewing and resolving claims pended or denied due to:

15
 (1) lack of authorization;
(2) questions regarding participant eligibility;
(3) incomplete itemization;
(4) non-standard claims information;
(5) balance billing;
(6) excess charges; and
(7) questions regarding whether services are allowable under Peace Corps’
Health Benefit Program.

j) Attach an appropriate Explanation of Benefits (EOB) notice to each reimbursement/payment

made under one of the Peace Corps’ three health benefit plans. The EOB shall include notice:
(1) that the reimbursement/payment is made according to Peace Corps’ Benefit
Program fee schedules and shall be considered payment in full for services;
(2) for PLAN II and PLAN III, that Peace Corps’ Health Benefit Program prohibits
billing beneficiaries for differences between claims made and claims paid; and
(3) explanation of claimants' rights to appeal disputed claims.

k) Administer a claims appeal procedure that enables Peace Corps’ Health Benefit Program
members and US service providers to dispute and to resolve disagreements over claims
payment in amounts of $250 or less.

l) Maintain secure, automated healthcare claims processing and accounting systems that provide
the following minimal features: documentation of responsibilities for system security and for
administration; documentation of claims system policies and procedures; security monitoring
procedures, user account and password security; data center security; daily backup procedures;
disaster recovery plan procedures; a business continuity plan; limited access to programs and
the ability to change programs based on various levels of system operators' needs to know and
utilize the same; and limited access to eligibility, beneficiary, and provider information based
on various levels of system operators' needs to know and utilize the same. Comply with
HIPAA Electronic Health Care Transactions and Code Sets standards. Provide, with Peace
Corps’ coordination, secure procedures that permit Peace Corps to transmit eligibility data,
authorize healthcare services, and obtain all Peace Corps Health Benefits Program information
held in the healthcare claims processing system.

m) Maintain, in the healthcare claims processing system, accurate, up-to-date provider

information.

n) Utilize and report for each claim the most current HCFA Common Procedural Codes, CMS,
revenue codes, CPT, ICD (International Classification of Diseases) diagnosis and procedure,
DSM (Diagnostic and Statistical Manual), and ADA (dental) codes for all health services
referenced in the claim.

o) Have the capacity to identify potential instances of fraudulent, abusive, or wasteful claims.
Thus, the healthcare claims processing system shall be automated to the degree that it:

(1) assures individual eligibility for benefits;

16
 (2) assures only claims for allowable services are reimbursed/paid;
(3) assures reimbursements/payments do not exceed established schedules;
(4) eliminates reimbursement/payment of duplicate claims;
(5) reconciles diagnosis codes to procedure and gender codes;
(6) compares the number of inpatient facility days on each claim against admission and
discharge dates; and
(7) compares claims made to claims reimbursed/paid.

p) Have the capacity to process claims under subrogation and claims involving no-fault.

q) Have the capacity to identify potential workers' compensation claims. The Adjudicator shall
refer such claims to the designated Peace Corps’ Federal Employees' Compensation Act
(FECA) liaison and assist that liaison in the determination of eligibility as needed. A
description of the Peace Corps’ FECA procedures appears in Section J.10. Confirm
attachments are correctly labeled.

r) Have the translation and currency conversion capacity to manage financial transactions that
occur as a result of healthcare services provided in foreign countries and shall report these
transactions to Peace Corps in terms of US dollars only.

s) Have the ability to make electronic funds transfer (EFT) for: 1) international bank transfer
payments via correspondent US financial institutions and 2) Applicant, PCV or RPCV
beneficiaries.

t) Conduct an internal audit of all claims in amounts greater than $10,000 made for services
provided to a single payee on behalf of a single beneficiary for a single incident

u) Monitor and report cost and utilization information associated with claim reimbursement

v) Recommend measures to control or reduce costs for the medical treatment services provided
beneficiaries of Peace Corps’ Health Benefits Program.

C.7.3 Quality Assurance of the Claims Component

The Contractor shall establish and maintain a quality assurance and improvement program, which
shall be approved by Peace Corps. This program shall include, but not be limited to, appropriate
standards and procedures for: 1) monitoring and improving claims made/paid turnaround times; 2)
monitoring and improving customer service response times; 3) monitoring and reducing the rates
of claims pended; 4) monitoring and reducing the rates of claims denied; 5) monitoring and
reducing financial and non-financial error rates; 6) documenting and resolving customer service
complaints.
C.7.4 Procedures and Reports of the Claims Component

17
C.7.4.1 Claims Component Procedures

The Contractor shall, 30 days after contract Date of Award, provide the Peace Corps with ongoing
electronic access to a procedures manual that conforms to a format mutually agreed upon by the
Contractor and Peace Corps. This procedures manual shall include, but is not limited to:

a) the names of the Claims Contractor's account representative and other key Contract
personnel, their phone and fax numbers, and their mailing addresses;

b) description of the appeals procedure to be used to resolve disputed claims in amounts of

$250 or less;

c) a description of the procedure for resolving complaints between Peace Corps personnel or
Peace Corps’ Health Benefits Program members and the Claims Contractor's healthcare
claims processing system personnel or customer service agents regarding authorizations or
claims inquiries;

d) a description of the business rules used to program the healthcare claims processing system
logic for eligibility, allowable benefits, and reimbursement/payment rates for claims made
under three benefit PLANs;

e) examples of the Explanation of Benefits used for Peace Corps’ three health benefit PLANs;

f) a description of the procedure and medium to be used by Peace Corps to transmit eligibility
information to, authorize services, and obtain information from the healthcare claims
processing system;

g) a description of the procedure to be used by Peace Corps to access health plan information
via electronic interface;

h) a description of the procedures to be undertaken in the event of electronic interface failure

or healthcare claims processing system shut-down;

i) a timetable for the delivery of monthly, quarterly, and annual reports; and

j) the dates of quarterly and annual meetings scheduled between the Contractor and Peace
Corps.

C.7.4.2 Claims Component Reports

The Contractor shall deliver to Peace Corps one hard copy and electronic access to each of the
following reports:
(1) At the time of contract award, and annually thereafter, submit one copy of the
accreditation from a nationally recognized accrediting organization and/or certification by
Medicare/Medicaid, and state licensing if appropriate;

18
 (2) Written notification of the completion of the update of the Medical Data Research
(MDR) fee schedule used by health care insurers, which establishes rates for health care
services by geographic location of service providers and provides the basis against which
the discounts shown herein are applied.

In addition, the Contractor shall provide monthly, quarterly and annual reports as follows:

Monthly:
(1) A summary of the claims paid, aggregate dollar amounts of claims made and of claims
paid, and average claim cost by fiscal year for each of the three health benefit PLANs. To
permit reconciliation with payments made to the Contractor, this report shall be generated
from the Contractor's accounting system;
(2) for the past month, a report of the findings of the Contractor's internal audits of claims in
amounts greater than $10,000;
(3) a fiscal year-to-date report of claims made/paid turnaround times for three health benefit
PLANs;
(4) a current report of claims pended, categorized by name, benefit PLAN, that identifies each
claim, dollar value of the claim made, provider name, date of service, date of claim,
member name, and reason for claim pended;
(5) for the past month, a report of claims denied, categorized by name, benefit PLAN, that
describes the numbers, reasons, and dollar value of claims denied;
(6) for the past month, a report of customer service inquiries made to the Contractor that
describes the number, means, and reason for inquiry;
(7) a fiscal year-to-date report of aggregate amounts paid to individual service providers listed
alphabetically in order of the payee's name that includes the payee's specialty, address, zip
code and Federal Identification Number or other identifier for foreign providers for the past
month reports on specific groupings to include, but not limited to Med-evac, a summary of
the claims paid, aggregate dollar amounts of claims made and of claims paid, and total
claim cost by fiscal year for each of the categories requested.
(8) for the past month, a summary report of total paid PLAN I, II and III the amount paid for
inpatient, outpatient, med-evac and aggregate year to date; and
(9) Annually, a summary report of the top 25 diagnoses by International Statistical
Classification of Diseases and Related Health Problems, aka ICD– 9 code, by dollar and
claim volume, organized by PLAN and provider.

Quarterly:
(1) (Ongoing) Electronic access to a database and/or electronic copy of the database organized
by PLAN that summarizes services provided to beneficiaries and that is organized in
alphabetical order of the member's last name. Detail shall include each beneficiary's Social
Security Number, date of birth, gender, country of service, ICD diagnosis codes or
Diagnostic and Statistical Manual (DSM) codes, Current Procedural Terminology (CPT)
codes reflecting the services provided, the state or country in which services were
provided, and the aggregate amount of reimbursements and/or payments made on behalf of
the beneficiary;
(2) Ongoing electronic access of fiscal year-to-date report of PLAN II and PLAN III
beneficiaries' institutional utilization rates that is organized alphabetically by facility that

19
 includes the number of admissions by ICD diagnosis codes or DSM code, the average
length of institutional stay, the average cost per day of stay, and the cost per admission; and
(3) electronic access to or hard copy of newly created or revised reporting formats, functions
or features.

Annually:
(1) a report that describes significant aspects of Peace Corps’ Health Benefits Program
including but not limited to a summary of claims made, claims reimbursed/paid, and
administrative costs paid;
(2) a report that identifies the 25 most common diagnoses of PLAN II and PLAN III
beneficiaries by ICD, DSM and/or CPT and descriptor, the frequency of the diagnoses, the
ages and genders of the beneficiaries served, and the aggregate amount of reimbursements
and/or payments made on behalf of the beneficiaries; and
(3) a report that describes the outcomes of the Contractor's quality assurance and improvement
efforts.

C.7.5 Claims Component Records

The Contractor shall:

a) Maintain online an accurate eligibility record for each Peace Corps Health Benefit Program
participant. These records shall reflect the eligibility information provided by Peace Corps and
in cases where Peace Corps may extend benefits to a dependent spouse or child of a
participant, the dependent's eligibility record shall be linked to the participant's unique
identifying number.

b) Maintain a procedure and medium for archiving data and information used in the
administration of Peace Corps’ Health Benefit Program, in a manner and medium acceptable to
Peace Corps.

c) Maintain a claims record for each individual beneficiary online during the term of the
member's eligibility and until the end of the two succeeding fiscal years. When this period has
elapsed, the member's claims record shall be retired by removing it from online status and
transferring it to the specified data archive medium. The Contractor shall maintain at least one
archive copy for a period of five fiscal years.

d) Systematically inventory, file, and securely store all claims submitted for reimbursement or
payment under Peace Corps’ Health Benefits Program on its premises for a period of five
years. The Contractor shall deliver on computer disc, archival copies of the claims inventory
to Peace Corps within 90 days after the close of each fiscal year and shall maintain at least one
archive copy of the inventory on its premises for a period of four fiscal years.

C7.5.1 Claims Component Record of Complaints

The Contractor shall maintain accurate and complete records of complaints regarding claims,
claims processing, claims documentation or other issues of concern that involve complaints of or

20
about claims. “Complaints” are defined as verbal or written notices of dissatisfaction with services.
These records shall be made available to Peace Corps upon the formal written request of the COTR
and or the Contracting Officer.

C.8 AIR AMBULANCE COMPONENT

C.8.1 Contract Requirements for Air Ambulance Component

The emergency medical evacuation service for PCVs working or traveling overseas during their
assignment assures and provides the Peace Corps access to prompt assistance. Emergency air
evacuations require a coordinated effort between the Contractor and Peace Corps and are used for
acute, life-threatening emergencies.

In the case of these emergencies, to ensure timely delivery of care, Peace Corps will request the
needed services of the Contractor. In addition to medical evacuations, these services may include
medical arrangements and healthcare management. The Contractor shall accept referrals for such
services 24 hours per day 7 days per week via telephone or other secure electronic means.

The Contractor will ensure that all business related and required licenses, credentialing, certificates
and insurance coverages are secured, maintained and renewed. The Contractor will provide
satisfactory assurances that all personnel will protect the confidentiality of protected health
information received from the Peace Corps.

The Contractor shall maintain communications with the Peace Corps overseas medical staff, and
COTR or international health coordinator from the Peace Corps Washington, DC headquarters
Office of Volunteer Support and Medical Services (VS/OMS) throughout the emergency
evacuation process. This includes, but is not limited to:

a) Providing periodic updates and progress reports approximately every two hours as to the
overall status of the evacuation, to include confirmation of available aircraft, landing
location, estimated arrival and departure times and selected medical facility;
b) The Contractor’s coordinating physician will contact the overseas medical staff to verify
contact information, obtain a more detailed summary of the case, and to assess the current
status of the Volunteer;
c) If needed, the Contractor will also contact the attending physician managing the case; and
d) Following departure, the Contractor will provide regular and consistent updates of the
Volunteer health status following the initial assessment and up until the arrival at the
destination facility.

C.8.2 Service Requirements for Air Ambulance Component

The Contractor shall arrange for all transportation and logistics associated with emergency
evacuations. This includes, but is not limited to:

a) Appropriate equipment, technology and qualified personnel;

21
 b) Transportation via land and/or air of the Volunteer from the in-country site of stabilization
to the airport;
c) Coordination and payment of related services including a Guarantee Payment Letter, if
needed and when approved and medically necessary, for a supervised evacuation;
d) Consulting medical advisor to provide case consultation and interim management advice to
the Peace Corps medical staff and local specialists;
e) Facilitating passage of the Volunteer through immigration and customs; and
f) Transportation of the Volunteer and other Peace Corps authorized accompaniments, when
needed, from current country location to an appropriate medical treatment destination and
receiving facility.

In general, after the medical evacuation has been initiated, the Contractor will provide a cost
estimate to include, at a minimum:

a) All necessary costs associated with the selected method of transportation via land and/or
air;
b) All daily charges for the medical team and pilot/technical crew;
c) All necessary medical equipment and medications;
d) All case fees accrued on an hourly or daily basis;
e) Ground transportation upon both departure and arrival; and
f) All telecommunication charges, ground handling and airport handling

After review and acceptance of the cost estimate, an authorized Peace Corps representative will
direct the Contractor to initiate medical emergency evacuation medical services. Should Peace
Corps not authorize these services; any associated expenses will not be incurred by Peace Corps.

C.8.3 Quality Assurance of Air Ambulance Component

The Contractor shall establish and maintain a quality assurance and improvement program, which
shall be approved by Peace Corps. This program shall include, but not be limited to, appropriate
standards and procedures for monitoring and improving emergency evacuation practices and
procedures.

C.8.4 Procedures and Reports for Air Ambulance Component

The Contractor will provide Peace Corps and the overseas post with the following transportation
information within two hours of the initial call requesting emergency medical evacuation services:

a) Medical evacuation destination, receiving facility, and attending physician;

b) Flight plan, estimated time of arrival (ETA) and periodic arrival updates;

c) Type of plane, plane tail sign, plane call sign; and

d) Name and nationality of the crew.

C.8.4.1 Air Ambulance Procedures

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The Contractor shall develop procedures, in consultation with Peace Corps, which will include, but
is not limited to:

a) Determination of the medical evacuation destination and the receiving facility;

b) Determination of required and authorized accompaniments and escorts;
c) Direct communication with the receiving facility to identify an attending physician and
organize reception of the Volunteer;
d) Determination of the medical personnel and skill requirements of the flight crew, surgeon,
anesthesiologist, nurse and other providers as determined by medical necessity;
e) Determination of the type of equipment needed in transport, oxygen, medications, life
support systems and other medically necessary items;
f) At the request of OMS, the contractor will monitor a patient on a daily basis until services
are discontinued;
g) Providing satisfactory assurances that staff and contracted personnel will protect the
confidentiality of protected health information received from the Peace Corps, as required
by HIPAA and the Privacy Act.
h) Determination, made on occasion, of the feasibility or accompaniment by family member
or Peace Corps staff.

C.8.4.2 Air Ambulance Reports

Following the completion of the evacuation and the discontinuation of services for a specific case,
the Contractor shall, in a timely manner, provide an outline of the case, detailed invoices and
utilization report. In addition, each individual outline and report will be included in a quarterly
summary of all services utilized for the specified time period. Reports and invoices will include,
but not be limited to:
a) Clinical summary report of the case;
b) Case summary that details contact between Peace Corps and the contractor, to include
dates, time, topic and actions taken;
c) Invoices should include line items and cost details for all related expenses and case fees in
both local currency and conversion to U.S. dollars.

C.8.5 Air Ambulance Records

The Contractor shall maintain incident, service and financial records for five years.

C.8.5.1 Air Ambulance Record of Complaints

The Contractor shall maintain a record of beneficiary complaints along with resolutions applied to
such complaints.

C.9 MEETINGS

The Contractor shall attend a meeting at Peace Corps headquarters in Washington, DC, shortly
after the award date.

The Contractor shall participate in quarterly meetings with the COTR and other appropriate Peace

23
Corps personnel throughout the duration of the contract.

Intermittently and as deemed necessary by the Peace Corps, upon the formal written request of the
COTR, the Contractor shall organize and attend meetings with Peace Corps personnel regarding
any and all services of the contract.

C. 10 SERVICES SUMMARY

General Performance Area Reference

Applicant Cost-Sharing Component C. 4
Network Provider Component C. 5
Pharmaceutical Component C. 6
Claims Component C. 7
Air Ambulance Component C. 8
Meetings C. 9

C. 10.1 Deliverables Summary Table

Please see the entire Statement of Work (C.1 – C.14), and all parts of the Request for
Proposal (RFP), for the performance deliverables and contract requirements. Note: all
references to days are business days.

Performance Requirements Reference Threshold

Applicant Cost-Sharing
Component
Summary Contract Deliverables
Summary Service Deliverables
Quality Assurance Plan
Procedures
Reports
Records
Record of Complaints
Network Provider Component
C.4
C.4.1 Manage and perform 100% of PLAN I.
C.4.2 Receive cost-share documentation, issue,
track, distribute and manage 100% of
cost-sharing for Applicants; deliver 100%
of customer service to Applicants who
inquire to the Contractor regarding PLAN
I.
C.4.3 10 days after award/kick-off meeting,
100%;
C4.4.1 Follow 100% of Peace Corps authorized
cost-sharing for PLAN I participants.
C4.4.2 Annual reports, 90 days after end of the
fiscal year, 100%; Monthly reports on
cost-sharing allowances issued or pending
by individual and by cost-share category
for medical, vision, and dental, 100%.
C.4.5 Maintain records for 5 years, 100%.
C4.5.1 Maintain a record of 100% of beneficiary
complaints and resolutions.
C.5 Verify and/or credential all participant

24

Network Provider Quality
Assurance Plan
Network Provider Procedures
Network Provider Reports
Network Provider Records
Network Provider Record of
Complaints
Pharmaceutical Component
providers and facilities utilized in each
networks, 100%; maintain appropriate
accreditation and/or certification of all
provider participants and facilities utilized
in each network, 100%; Inform all
provider participants of requirements and
policies prior to contract implementation
and within 30 days of contract renewals or
modifications, 100%; Affiliated service
providers have 24-hour phone access and
24-hour access to emergency services, 365
days a year, 100%; respond to all phone
inquiries within 24 hours, 100%; written
reports submitted within 5 days of the end
of a course of evaluation or treatment,
100%; Addition of new providers in
service network within 20 days of request
by Peace Corps, 100%; Participating
practitioners and facilities refrain from
billing or collecting any balance that
exceeds authorized payment or
reimbursement amounts, 100%; Assure
access to pharmaceutical services, 100%;
provide identification cards to Plan II/III
beneficiaries, 100%;
C.5.7 Deliver 10 days after award/kick-off
meeting, 100%;
C.5.8.1 Provide access to and an electronic access
manual of all component providers,
routine and emergency procedures, and all
business processes, 30 days after contract
award, 100%;
C.5.8.2 Annual credentialing, certification or
accreditation reports, 90 days after end of
the fiscal year, 100%; Semi-Annual and
Quarterly activity reporting, 100%.
C.5.9 Maintain required records on participant
providers and service facilities, 100%.
C.5.9.1 Maintain a file of 100% of the complaints
against any and all participant providers,
100%.
C.6 Provide access to managed prescription
drug service for PLAN II beneficiaries,
100%; Appoint ongoing liaison to Peace
Corps, 100%; Assure access to services 24
hours a day and 365 days a year, 100%;
25
 Provide ID cards for pharmaceutical
services, 100%; Inform participant
pharmaceutical service providers of
service requirements and policies prior to
contract implementation and within 30
days following any renewals or
modifications, 100%.
Quality Assurance Plan C.6.3 Deliver 10 days after award/kick-off
meeting, 100%.
Procedures C.6.4.1 Deliver 30 days after Date of Award, 1
copy and ongoing electronic access to a
completed procedures manual, 100%.
Reports C.6.4.2 Beginning 30 days after Date of Award,
provide access to a monthly drug
utilization report, 100%; Annual reports,
90 days after end of the fiscal year, 100%.
Records C.6.5 Maintain a claim records for each
beneficiary, 100%.
Record of Complaints C.6.5.1 Maintain a complete record of complaints
and resolutions for all aspects of
pharmaceutical services, 100%.
Claims Component C.7 Maintain copies of bills for 5 years,
100%; provide customer service from 9am
– 6 PM on all US government workdays,
100%; Provide claims processors and toll-
free telephone service, 100%; Provide
Letters of Guarantee Payment as
necessary, 100%; Adjudicate domestic
claims for services within 20 days, 100%;
Adjudicate international claims for
services within 30 days, 100%; Attach
EOB notices to payment distributions
including that payment is made according
to PC policy and fee schedule and shall be
considered payment in full, 100%;
identify claims by HCFA Common
Procedural Codes, CMS, CPT, ICD, DSM
and ADA health service codes, 100%;
monitor cost/resource utilization data,
100%; negotiate and achieve discounted
network fee within 20 days of claim,
100%.
Quality Assurance Plan C.7.3 Deliver 10 days after award/kick-off
meeting, 100%.
Procedures C.7.4.1 Provide 30 days after Date of Award,
access to an electronic completed

26
 procedures manual, 100%.
Reports C.7.4.2 Provide accreditation report and
confirmation of updated MDR fee
schedule at the award/kick-off meeting,
100%; Report monthly on all network fee
savings and any additional negotiated
savings, 100%; Annual reports, 90 days
after end of the fiscal year; Monthly
reports 5 days after the end of the month,
100%.
Records C.7.5 Maintain accurate eligibility records for
participants, 100%. Maintain and provide
all claim activity data reports, 100%.
Record of Complaints C.7.5.1 Maintain a complete record of complaints
and resolutions regarding claims and any
aspect of claim processing, 100%.
Air Ambulance Component C. 8 Coordinate with Peace Corps, provide
periodic updates every 2 hours as to the
overall status of the Volunteer and travel
schedule until arrival at destination,
100%; arrange all transportation and
logistics for emergency evacuation, 100%;
provide cost estimate of medical
evacuation and seek approval from
authorized Peace Corps representative,
100%.
Quality Assurance Plan C.8.3 Deliver 30 days before the start of Air
Ambulance services, 100%.
Procedures and Reports C.8.4 Provide all required information to PC
post regarding emergency evacuation
logistics and healthcare personnel or
facilities, 100%; determine and develop
air ambulance procedures together with
Peace Corps upon award/kick-off
meeting, 100%; Clinical and case
summary together with invoices shall be
provided ASAP, 100%.
Records C.8.5 Maintain incident, service and financial
records for 5 years, 100%.
Record of Complaints C.8.5.1 Maintain a record of all beneficiary
complaints and resolutions for review
with Peace Corps staff, 100%.
Meetings C. 9 Attend Award/Kick-off Meeting, 100%;
attend quarterly meetings at Peace Corps
headquarters, 100%; attend intermittent
meetings arranged as necessary by the

27
 COTR, 100%.
C.11 PAYMENTS TO THE CONTRACTOR

The Contractor shall:

A) Present to Peace Corps a detailed invoice for administrative costs due the Contractor
for services rendered under the contract on a monthly basis beginning the month
following the first month of service and every month thereafter. Include the cost of
each component in the monthly invoice.

B) Present to Peace Corps no less frequently than on a weekly basis, an itemization of the
amounts due beneficiaries and service providers for allowable, authorized claims. This
itemization shall be organized by benefit PLAN, within the fiscal year accrued and
shall show the aggregate amounts claimed under each PLAN. Within each benefit
PLAN, the claims presented shall include: the name, address, zip code and Federal
Identification Number or Social Security Number of the payee, the payee's invoice
number if an invoice has been provided, the beneficiary's name and Social Security
Number, the ICD, DSM and/or CPT codes and a description of the services provided,
the amount of the claim made and the amount of the claim reimbursed/paid.

C) Present to Peace Corps a detailed invoice of negotiated or standard network savings

offered by the Contractor. (This may be known as the network fee or the Contractor’s
network savings amount).

Procedures for transferring these payments to the Contractor and for issuing Peace Corps Health
Benefit checks to claimants shall be proposed by the Contractor and established by Peace Corps at
the time of contract award.

C.12 TRANSITION AND IMPLEMENTATION

After the contract Date of Award, the Contractor shall:

a) Designate an account representative to serve as ongoing liaison to Peace Corps.

b) Attend such meetings as are necessary to the effective implementation of the Contract.
c) Assure an effective transition to any new systems, procedures and collateral materials. For
example, successful performance may require the Contractor to initiate an outline of steps
and methods to achieve successful transfer of necessary data and system access.
d) Reach agreement with Peace Corps’ COTR regarding the actions the Contractor shall
undertake to inform the provider networks (Washington, DC Service Network, national
PPO, and international PPO) and the managed prescription drug service providers, of Peace
Corps’ service requirements and undertake the same.
e) Reach agreement with Peace Corps’ COTR regarding the actions the Contractor shall
undertake to inform the Washington, D.C. Service Network, existing Open Panel providers,
the National PPO Network and the managed prescription drug service providers of Peace
Corps’ service requirements and undertake the same.

28
 f) Assure access to telephone services that shall be used to receive inquiries made by Peace
Corps, Health benefit members and RPCVs.
g) Provide to Peace Corps’ COTR ongoing electronic access to a basic procedures manual
that describes:
(1) the names of the Contractor's account representative and other key Contract
personnel, their phone and fax numbers, and their mailing addresses;
(2) as appropriate to the services to be provided, a link to or a directory of the service
h) providers to be used under the contract that includes the providers' names, specialties,
phone and fax numbers, and their mailing addresses; and (3) routine and emergency
procedures for accessing services provided by the Contractor.
i) As appropriate to the services to be provided, conduct an orientation for Peace Corps’
Office Volunteer Support – Medical Services to explain eligibility information transfer
procedures, authorization procedures, claims inquiry procedures, procedures for accessing
service providers, and other procedures necessary for the effective administration of the
plan.
j) Provide appropriate training to designated Peace Corps personnel and customer service
agents on the service requirements.
k) Provide access to appropriate Peace Corps personnel of any Contractor internal data
systems necessary to monitor and account for performance.
l) As appropriate to the services to be provided, outline the electronic and secured system
method(s) that are available to be used to transmit claims activity and eligibility data.
Reach agreement with Peace Corps on the method that will be used to transmit eligibility,
claims and other pertinent information.
m) As appropriate to the services to be provided, reach agreement with Peace Corps on the
format and design of printed materials to be used in the administration of service
components and produce the same.
n) Provide such written materials to include Health Benefits Card and Pharmacy Card.
o) Designate and train the Contractor's personnel and customer service agents on the service
requirements of Peace Corps’ Health Benefits Program.

C.13 RESPONSIBILITIES OF PEACE CORPS

Peace Corps will:

a) Provide a Contracting Officer's Technical Representative (COTR) for purposes of ongoing

liaison with the Contractor during performance.

b) Maintain a self-insured health benefit program with three benefit PLANs. The PLANs are
known as:
a. PLAN I: Applicants;
b. PLAN II: Peace Corps Volunteers (PCVs) and their minor dependents; and
c. PLAN III: Returned Peace Corps Volunteers (RPCVs). This includes FECA claims
as well as authorizations for evaluation of Peace Corps related conditions for up to
six months post service.

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 c) Determine benefits allowable under each PLAN.

d) Establish eligibility for each benefit PLAN.

e) Authorize services for beneficiaries covered in each PLAN.

f) Convey to the Contractor via secure medium the eligibility roster for each of its benefit
PLANs on a weekly basis. This roster will include the name, Social Security Number, and
effective dates of coverage for each PLAN participant.

g) Annually approve fee schedules for reimbursements allowed to beneficiaries and payments
allowed to service providers for eligible Health Benefits Program participant healthcare.
h) Annually approve any changes to the plan design, premium level and eligibility
requirements.
i) Provide and administer: 1) an appeals procedure to review and render a final determination
on any reimbursement or payment denied by Contractor on any claim while acting in
accordance with Peace Corps’ policy; and 2) an appeals procedure to receive, review,
resolve, and make a final determination on disputes arising over claims made by Peace
Corps’ Health Benefit Program members or by service providers.

j) Arrange for and will provide routine medical care, preventive health services, and health
promotion to PLAN II PCVs serving overseas.

k) Determine air ambulance transportation needs and logistical support to PLAN II PCVs who
are med-evaced from overseas assignments due to a need for medical, mental health, or
dental evaluation and treatment in the US or at intermediate locations worldwide.

l) Manage the course of evaluation and treatment of PLAN II PCVs who receive medical,
mental health, or dental evaluation and treatment in the US or at intermediate locations
worldwide with or without air ambulance transportation

m) Determine whether a PLAN II PCV will be returned to an overseas work assignment within
45 days of a PLAN II PCV's med-evac or evaluation and treatment in the US or at
intermediate locations worldwide.

n) Designate a liaison for and manage all workers' compensation claims made on behalf of
PLAN III RPCVs under the Federal Employees' Compensation Act (FECA).

C.13.1 Responsibilities of the Peace Corps

and Air Ambulance Transportation and Logistics

Peace Corps will contact the Contractor to request service and provide the following information:

a) Demographic and clinical information to include Volunteer’s name, date of birth and social
security number;
b) Case summary, diagnosis, Volunteer’s health status, and treatment initiated;

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 c) Points of contact, telephone and fax numbers of the relevant Peace Corps medical staff;
d) Geographic location of the ill or injured Volunteer;
e) Name and telephone number of the local attending physician, hospital or clinic; and
f) Telephone and fax number of the U.S. Embassy.

Peace Corps will assist the Contractor, when necessary, in obtaining the following logistical
information:

a) Local airport facilities hours of operation, length of runway, runway surface, availability of
night lights and other logistical requirements associated with transportation;
b) Flight permission and landing rights, procedures for obtaining airspace, immigration and
landing rights;
c) Assistance from the U.S. Embassy, if required;
d) Landing fees at the national airport and required method of payment;
e) Local refueling procedures and availability of aviation fuel, approximate cost of
refueling and method of payment; and
f) Ambulance protocols and procedures for getting an ambulance and attendants onto the
runway.

Once the emergency rescue has been initiated, Peace Corps will receive from and relay the
following information to the Contractor and relevant Peace Corps posts located overseas:

a) Verification that OMS has obtained services of an emergency evacuation contractor;

b) Confirmation of the contractor’s intent to contact the Peace Corps overseas post and
provide the name of their coordinating physician;
c) Medical evacuation destination, receiving facility and attending physician at the receiving
facility; and
d) Estimated flight time for arrivals and departures.

After arrival of the Volunteer to the destination, Peace Corps will maintain and facilitate
communication:

a) Between the overseas staff and the contractor’s physician coordinator throughout the
evacuation process;
b) To provide for authorization of services needed to guarantee payment to hospitals and
physicians at the final medical evacuation site and for all of the contractors’ services; and
c) To insure notification of discontinuation of contractor services when appropriate.

C.14 RIGHTS RESERVED TO PEACE CORPS

Peace Corps reserves the right to:

1. Establish eligibility requirements and reimbursement rates for all of its Health Benefit
Programs, including the right to extend health benefits to the dependent spouses and/or child or
children of PLAN II PCVs or PLAN III RPCVs.

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2. Determine the need for an emergency medical evacuation of a PLAN II beneficiary.

3. Determine where and from whom Health Benefit Program beneficiaries receive medical,
mental health, or dental evaluation or treatment, including the right to make referrals outside
the Contractor's Service Network.

4. Obtain and hold copies of beneficiaries' medical records and documents generated in the course
of authorized health evaluation or treatment. Copies of these records and documents shall
remain the property of Peace Corps.

5. Access all claims records and eligibility data held by the Contractor. These records and data
shall remain the property of Peace Corps.

6. Audit, or to cause to be audited by its designee, all claims, administrative, and financial records
related to the management of its Health Benefits Program.

7. Make a final determination of disputed claims made by beneficiaries or by service providers

for reimbursement or payment made under its Health Benefit Program.

8. Deny any claim presented by the Contractor for reimbursement or payment. Reasons for
denying claim reimbursement or payment to the Contractor include, but are not limited to,
failure of a claimant to provide copies of requested medical records or reports to Peace Corps
medical personnel; failure of a claimant affiliated with the Contractor's Washington, D.C.
Service Network to adhere to Peace Corps "no balance billing" requirement; claims presented
on behalf of an ineligible person; claims presented that exceed established fee schedules;
claims presented for unauthorized or disallowed services; claims presented that are duplicative
or fraudulent. This does not limit the Contractor's rights under the Contract Disputes Act of
1978 (41 USC. 601-613), as implemented by FAR 52.233-1 & -4.

9. Make site visits to the Contractor and/or to providers and/or facilities affiliated with a Service
Network throughout the term of the Contract.

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