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CALIFORNIA RURAL INDIAN HEALTH BOARD INC

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					       CALIFORNIA RURAL INDIAN HEALTH BOARD, INC.




                 REQUEST FOR PROPOSALS
TO PROVIDE A THIRD PARTY ADMINISTRATOR FOR A LOW INCOME
HEALTH PROGRAM (“LIHP”) CLAIMS, UTILIZATION MANAGEMENT,
               AND ADMINISTRATIVE SERVICES




             PROPOSALS WILL BE RECEIVED UNTIL
            THE CLOSE OF BUSINESS, MARCH 19, 2012
                     AT THE OFFICES OF:

          CALIFORNIA RURAL INDIAN HEALTH BOARD, INC.
               4400 AUBURN BLVD, SECOND FLOOR,
                     SACRAMENTO, CA 95841




                        MARCH 2, 2012




                              1
                        CALIFORNIA RURAL INDIAN HEALTH BOARD, INC.


                          REQUEST FOR PROPOSALS
      TO PROVIDE A THIRD PARTY ADMINISTRATOR (TPA) FOR A LOW INCOME
        HEALTH PROGRAM (LIHP) CLAIMS, UTILIZATION MANAGEMENT, AND
                         ADMINISTRATIVE SERVICES


NOTICE INVITING PROPOSALS ......................................................................................... 5

PROPONENT'S CHECKLIST ............................................................................................... 6

1.0      GENERAL INFORMATION ....................................................................................... 7

1.1      REQUEST FOR PROPOSAL (RFP) PROCESS ....................................................... 7

1.2      INVITATION TO SUBMIT A PROPOSAL ................................................................. 7

1.3      CONSEQUENCE OF SUBMISSION OF PROPOSAL .............................................. 7

1.4      ACCEPTANCE OR REJECTION OF PROPOSAL ................................................... 7

1.5      RIGHT TO CHANGE OR AMEND REQUEST ........................................................... 8

1.6      CANCELLATION ...................................................................................................... 8

1.7      EXAMINATION OF PROPOSAL MATERIALS ......................................................... 8

1.8      ADDENDA AND INTERPRETATION ........................................................................ 8

1.9      DISQUALIFICATION ................................................................................................ 9

1.10     INFORMAL PROPOSAL REJECTED ....................................................................... 9

1.11     CONDITIONS TO BE ACCEPTED IF ANY WORK IS SUBCONTRACTED.............. 9

1.12     LICENSING REQUIREMENTS ............................................................................... 10

1.13     INSURANCE REQUIREMENTS ............................................................................. 10

1.14     HOLD HARMLESS DEFENSE CLAUSE ................................................................ 10

1.15     APPLICABLE LAW ................................................................................................ 10

1.16     METHOD OF PAYMENT......................................................................................... 10

1.17     TERM ...................................................................................................................... 10


                                                                    2
1.18    COMPETITIVE PRICING ........................................................................................ 10

1.19    FUNDING ................................................................................................................ 11

1.20    UNCONDITIONAL TERMINATION FOR CONVENIENCE..................................... 11

1.21    AUDITING OF CHARGES AND SERVICES ............................................................................ 11

1.22    CHANGES .............................................................................................................. 11

1.23    AWARD .................................................................................................................. 11

1.24    LIQUIDATED DAMAGES ....................................................................................... 11

1.25    PRODUCT OWNERSHIP ........................................................................................ 11

1.26    CONFIDENTIALITY ................................................................................................ 11

2.0     GENERAL NATURE OF SERVICES ...................................................................... 12

2.1     BACKGROUND ...................................................................................................... 12

2.2     PURPOSE ............................................................................................................... 13

2.3     SCOPE OF SERVICES ........................................................................................... 14

        2.3.1     INCLUDED TPA SERVICES ....................................................................... 14

        2.3.2     EXCLUDED TPA SERVICES ...................................................................... 20

2.4     OTHER REQUIREMENTS ...................................................................................... 20

3.0     PROPOSAL GUIDELINES, CONTENT AND FORMAT .......................................... 20

3.1     EVALUATION PROCEDURE AND CRITERIA ....................................................... 22

3.2     PROPOSAL DEVELOPMENT COSTS ................................................................... 23

3.3     PROPONENT CONTACT ....................................................................................... 23

3.4     CRIHB’S USE OF PROPOSAL MATERIAL ........................................................... 23

3.5     REJECTION OF PROPOSAL ................................................................................. 23

APPENDIX A: PROPONENT’S AGREEMENT .................................................................. 24

APPENDIX B: NON-COLLUSION AFFIDAVIT .................................................................. 25



                                                                 3
APPENDIX C: INSURANCE REQUIREMENTS ................................................................. 26

APPENDIX D: SUPPLEMENTAL QUESTIONNAIRE......................................................... 28

APPENDIX E: LIST OF TRIBAL HEALTH CLINICS

APPENDIX F: EXPECTED TERMS OF THE LIHP AGREEMENT BETWEEN CRIHB
AND THE CALIFORNIA DEPARTMENT OF HEALTH CARE SERVICES




                                                    4
                               NOTICE INVITING PROPOSALS

NOTICE IS HEREBY GIVEN that Requests for Proposals (RFP) are invited by the California
Rural Indian Health Board, Inc. (CRIHB) for specifications to provide Low Income Health
Program (LIHP) Claims/Administrative Services in strict accordance with the specifications.

CRIHB is seeking proposals from qualified Third Party Administrator (TPA) firms to provide
claims/administrative services for its LIHP that will cover approximately 2,000 eligibles in
strict accordance with the specifications.

Proposal forms and specifications are available on the CRIHB website at
http://www.crihb.org and at the CRIHB office, 4400 Auburn Blvd, Second Floor, Sacramento,
CA 95841, up to but not later than, close of business March 19, 2012.

CRIHB reserves the right to reject any and/or all proposals received.

                                          RFP Officer
                                       Ms. Jackie Kaslow
                           California Rural Indian Health Board, Inc.
                       Director, Family and Community Health Services
                                        (916) 929-9761
                                  Jackie.Kaslow@CRIHB.net

DISCLAIMER: CRIHB does not assume any liability of responsibility for errors/omissions in any
document transmitted electronically.

Dated: March 2, 2012




                                                5
                                  PROPONENT'S CHECKLIST
                         CALIFORNIA RURAL INDIAN HEALTH BOARD, INC.

Did You:

* Sign and notarize by jurat certificate the "Non-Collusion Affidavit" form. An "All-Purpose
Acknowledgment" form will not be sufficient.

*   Complete and sign the "Proponent's Fee Schedule" form, (under separate cover).

*   Sign the "Proponent’s Agreement" form.

*   Include with proposal, name and e-mail address of the individual for CRIHB to contact.

*   Submit one (1) ORIGINAL and FOUR (4) copies of all proposal documents.

*   Review all clarifications/questions/answers on the CRIHB website at: http://www.crihb.org

* Deliver sealed proposal to CRIHB, 4400 Auburn Blvd. Second Floor, Sacramento, CA 95841, before
the close of business March 19, 2012. Sealed proposal shall be marked:

       “PROPOSAL: RFP – TO PROVIDE A THIRD PARTY ADMINISTRATOR (TPA) FOR LIHP
       CLAIMS, UTILIZATION MANAGEMENT, AND ADMINISTRATIVE SERVICES”

                                      CONTACT INFORMATION:
     Information on RFP Specification, Bid Process/Clarification
     Ms. Jackie Kaslow
     (916) 929-9761 – Jackie.Kaslow@CRIHB.net


*If not completed as required, your proposal may be voided.

DISCLAIMER: CRIHB does not assume any liability or responsibility for errors/omissions in any
document transmitted electronically.

THIS FORM IS FOR YOUR INFORMATION ONLY AND DOES NOT NEED TO BE SUBMITTED WITH
YOUR PROPOSAL.




                                                    6
                           REQUEST FOR PROPOSALS (RFP)
                    TO PROVIDE A THIRD PARTY ADMINISTRATOR (TPA)
      FOR LOW INCOME HEALTH PROGRAM (LIHP) CLAIMS, UTILIZATION MANAGEMENT, AND
                           ADMINISTRATIVE SERVICES

1.0   GENERAL INFORMATION

1.1   REQUESTS FOR PROPOSAL (RFP) PROCESS

      The purpose of this Request for Proposal is to request proponents to present their
      qualifications and capabilities to provide a third party administrator for Low Income Health
      Program claims, utilization management, and administrative services operated by the California
      Rural Indian Health Board, Inc.

1.2   INVITATION TO SUBMIT A PROPOSAL

      Proposals shall be submitted no later than the close of business on March 19, 2012 to:

                                   Ms. Jackie Kaslow, RFP Officer
                              California Rural Indian Health Board, Inc.
                                   4400 Auburn Blvd. Second Floor
                                       Sacramento, CA 95841

      One (1) original and FOUR (4) copies of the proposal shall be submitted. The proposal should be
      firmly sealed in an envelope that shall be clearly marked on the outside, "Third Party
      Administrator (TPA) for LIHP Claims, Utilization Management, and Administrative Services for
      CRIHB." Any proposal received after the due date may not be accepted and may be rejected and
      returned, unopened, to the proponent.

      Proponent may submit more than one proposal provided the proposal meets the functional
      requirements.

1.3   CONSEQUENCE OF SUBMISSION OF PROPOSAL

      A.     CRIHB shall not be obligated to respond to any proposal submitted nor be legally
             bound in any manner by the submission of a proposal.

      B.     Acceptance by CRIHB of a proposal obligates the proponent to enter into an
             agreement with CRIHB.

      C.     An agreement shall not be binding or valid against CRIHB unless or until it is
             executed by CRIHB and the proponent.

      D.     Statistical information contained in these documents is for informational purposes only.
             CRIHB shall not be responsible for the accuracy of said data. CRIHB reserves the right to
             increase or decrease the project scope.

1.4   ACCEPTANCE OR REJECTION OF PROPOSAL

      CRIHB reserves the right to select the successful proposal and negotiate an agreement as to the

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      scope of services, the schedule for performance and duration of the services with proponent(s)
      whose proposal(s) is/are most responsive to the needs of CRIHB. Further, CRIHB reserves the
      right to reject any and all proposals, or alternate proposals, or waive any informality or irregularity
      in the proposal as is in CRIHB's best interest.

      CRIHB reserves the right to reject any and all proposals, or portions thereof, received in
      response to the Request or to negotiate separately with any source whatsoever, in any
      manner necessary, to serve the best interests of CRIHB. Additionally, CRIHB, for any reason,
      may decide not to award an agreement(s) as a result of this Request.

      Non-acceptance of any proposal shall not imply that the proposal was deficient. Rather, non-
      acceptance of any proposal will mean that another proposal was deemed to be more
      advantageous to CRIHB or that CRIHB decided not to award an agreement as a result of this
      Request.

1.5   RIGHT TO CHANGE OR AMEND REQUEST

      CRIHB reserves the right to change the terms and conditions of this Request. CRIHB will notify
      potential proponent(s) of any material changes by posting on CRIHB’s website. No one is
      authorized to amend any of the Request requirements in any respect, by an oral statement, or to
      make any representation or interpretation in conflict with their provisions. If necessary,
      supplementary information and/or clarifications/questions/answers will be posted on CRIHB’s
      website at http://www.crihb.org. The failure of any proponent to not have received such
      information and/or clarifications/questions/answers shall not relieve such proponent from any
      obligation under his/her proposal as submitted.

      Any exceptions to this Proposal shall be clearly stated in writing.

1.6   CANCELLATION

      CRIHB reserves the right to rescind award of the contract at any time before execution of the
      contract by both parties if rescission is deemed to be in CRIHB best interest. In no event shall
      CRIHB have any liability for the rescission of award. The proponent assumes the sole risk and
      responsibility for all expenses connected with the preparation of its proposal.

1.7   EXAMINATION OF PROPOSAL MATERIALS

      The submission of a proposal shall be deemed a representation and warranty by the proponent
      that it has investigated all aspects of the Request, that it is aware of the applicable facts
      pertaining to the Request process and its procedures and requirements, and that it has read and
      understands the Request. No request for modification of the provisions of the proposal shall be
      considered after its submission on the grounds the proponent was not fully informed as to any
      fact or condition. Statistical information which may be contained in the Request or any addendum
      is for informational purposes only. CRIHB disclaims any responsibility for this information which
      may subsequently be determined to be incomplete or inaccurate.

1.8   ADDENDA AND INTERPRETATION

      CRIHB will not be responsible for, nor be bound by, any oral instructions, interpretations, or
      explanations issued by CRIHB or its representatives. Any request for clarifications/questions/
      answers of this Request shall be made in writing/e-mail and deliverable to:


                                                     8
                                California Rural Indian Health Board, Inc.
                                          Attn: Ms. Jackie Kaslow
                                Director, Family and Community Services
                                     4400 Auburn Blvd. Second Floor
                                         Sacramento, CA 95841
                                       Jackie.Kaslow@CRIHB.NET

       Such request for clarifications/questions/answers shall be delivered to CRIHB at least ten (10)
       calendar days prior to the date for receipt of proposals. Any CRIHB response to a request for
       clarifications/questions/answers will be posted on CRIHB’s website at http://www.crihb.org (not
       later than five (5) calendar days prior to the due date), and will become a part of the Request.
       Then proponent should await responses to inquires prior to submitting a proposal.

1.9    DISQUALIFICATION

       Any of the following may be considered cause to disqualify a proponent without further
       consideration:

       A.     Evidence of collusion among proponents;

       B.     Any attempt to improperly influence any member of the evaluation panel;

       C.     A proponents default in any operation of a professional services agreement which result in
              termination of that agreement, and/or

       D.     Existence of any lawsuit, unresolved contractual claim, or dispute between proponent
              and CRIHB.

1.10   INFORMAL PROPOSAL REJECTED

       A proposal shall be prepared and submitted in accordance with the provisions of these Request
       instructions and specifications. Any alteration, omission, addition, variance, or limitation of, from,
       or to a proposal may be sufficient grounds for rejection of the proposal. CRIHB has the right to
       waive any defects in a proposal if CRIHB chooses to do so. CRIHB may not accept a proposal
       if any document or item necessary for the proper evaluation of the proposal is incomplete,
       improperly executed, indefinite, ambiguous, or missing.

1.11   CONDITIONS TO BE ACCEPTED IF ANY WORK IS SUBCONTRACTED

       A.     The proponent assumes full responsibility, including insurance and bonding
              requirements, for the quality and quantity of all work performed.

       B.     If proponent's supplier(s) and/or subcontractor's involvement requires the use of a
              licensed, patented, or proprietary process, the proponent of the process is responsible for
              assuring that the subcontractor, supplier, and/or operator have been properly authorized
              to use the process or for providing another process which is comparable to that which is
              required prior to submission of a proposal.

       C.     Subcontractor shall agree to any and all inspection rights afforded to CRIHB under any
              agreement with the Proponent. Proponent must provide documentation that such rights of
              inspection are expressly stated in any and all agreements between the Proponent and its
              subcontractors.

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1.12   LICENSING REQUIREMENTS

       Any professional certifications or licenses that may be required will be the sole cost and
       responsibility of the successful proponent.

1.13   INSURANCE REQUIREMENTS

       Proponent, at proponent's sole cost and expense and for the full term of the resultant agreement
       or any extension, shall obtain and maintain at least all of the insurance requirements listed in
       Exhibit A.

       All policies, endorsements, and certificates shall be subject to approval by the designee of the
       CRIHB RFP Officer as to form and content. These requirements are subject to amendment or
       waiver if so approved in writing by the designee. Proponent agrees to provide CRIHB with a copy
       of said policies, certificates, and/or endorsements.

       The proponent shall satisfy these insurance requirements concurrently with the signing of the
       contract prior to commencement of work. Please contact Ms. Jackie Kaslow, CRIHB RFP
       Officer at (916) 929-9761.

       All coverage shall be provided by a carrier authorized to transact business in California and shall
       be primary.

1.14   HOLD HARMLESS DEFENSE CLAUSE

       The contractor shall indemnify, defend, and save harmless CRIHB against all loss, cost, or
       damage on account of any injury to persons or property, including employees or property of
       CRIHB, contractor or third parties, occurring in the performance of the contract.

1.15   APPLICABLE LAW

       This agreement shall be governed by the laws of the State of California. Venue shall be proper in
       the Superior Court of the State of California, County of Sacramento, or, for actions brought in
       Federal Court, the United States District Court for the Eastern District of California, Sacramento
       Division.

1.16   METHOD OF PAYMENT

       Payment will be made within thirty (30) days after invoices are received and accepted by CRIHB’s
       Executive Director. Invoices are to be submitted monthly.

1.17   TERM

       The proposed agreement will be for a period to begin on July 1, 2012 and end December 31,
       2013.

1.18   COMPETITIVE PRICING

       Proponent warrants and agrees that each of the charges, economic or product terms or
       warranties granted pursuant to this Contract are comparable to or better than the equivalent
       charge, economic or product term or warranty being offered to any similarly situated commercial

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       or other government customer of proponent. If proponent enters into any arrangements with
       another customer of proponent to provide product under more favorable charges, economic or
       product terms or warranties, proponent shall immediately notify CRIHB of such change and this
       Contract shall be deemed amended to incorporate the most favorable charges, economic or
       product terms or warranties.

1.19   FUNDING

       Any contract which results from this Request will terminate without penalty at the end of the fiscal
       year in the event funds are not appropriated for the next fiscal year. If funds are appropriated for
       a portion of the fiscal year, this contract will terminate without penalty, at the end of the term for
       which funds are appropriated.

1.20   UNCONDITIONAL TERMINATION FOR CONVENIENCE

       CRIHB may terminate the resultant agreement for convenience by providing sixty (60) calendar
       day advance notice unless otherwise stated in writing.

1.21   AUDITING OF CHARGES AND SERVICES

       CRIHB reserves the right to periodically audit all charges and services made by the successful
       proponent to CRIHB for services provided under the contract. Upon request, the proponent
       agrees to furnish CRIHB with necessary information and assistance to perform the auditing as
       may be deemed necessary by CRIHB.

1.22   CHANGES

       CRIHB’s Representative has the authority to review and recommend or reject change orders and
       cost proposals submitted by the proponent or as recommended by the proponent’s project
       manager.

1.23   AWARD

       Upon conclusion of the Request process, a contract may be awarded by CRIHB.

       CRIHB reserves the right to select the successful proponent and to negotiate terms of a contract
       with the proponent(s) whose proposal(s) is/are most responsive to the needs of CRIHB. Further,
       CRIHB reserves the right to reject any and all proposals, or alternate proposals, or waive any
       informality in the proposal as is in CRIHB's best interest.

1.24   LIQUIDATED DAMAGES

       N/A

1.25   PRODUCT OWNERSHIP

       Any documents, products or systems resulting from the contract will be the property of CRIHB.

1.26   CONFIDENTIALITY

       If proponent believes that portions of a proposal constitute trade secrets or confidential

                                                     11
      commercial, financial, geological, or geophysical data, then the proponent must so specify by, at
      a minimum, stamping in bold red letters the term "CONFIDENTIAL" on that part of the proposal
      which the proponent believes to be protected from disclosure. The proponent must submit in
      writing specific detailed reasons, including any relevant legal authority, stating why the proponent
      believes the material to be confidential or a trade secret. Vague and general claims as to
      confidentiality will not be accepted. CRIHB will be the sole judge as to whether a claim is general
      and/or vague in nature. All offers and parts of offers that are not marked as confidential may be
      automatically considered public information after the contract is awarded. The proponent is
      hereby given notice that CRIHB may consider all or parts of the offer public information
      under applicable law even though marked confidential.

2.0   GENERAL NATURE OF SERVICES

2.1   BACKGROUND

      The California Rural Indian Health Board, Inc. (CRIHB) was founded and incorporated in 1969 by
      a consortium of nine California Indian Tribes to advocate for the return of federal health care
      services to the American Indian population of California. Those services had been withdrawn in
      the 1950's as part of the federal policy of termination that resulted in the loss of federal tribal
      status to numerous small tribes. Through the efforts of this organization decades of shameful
      neglect of Indian health problems was brought to an end.

      As stated in CRIHB’s corporate bylaws: "This corporation is formed to provide a central focal
      point in the Indian health field in California for planning, advocacy, funding, training, technical
      assistance, coordination, fund-raising, education, development and for the purpose of promoting
      unity and formulating common policy on Indian health care issues."

      CRIHB is currently sanctioned by 31 tribes to operate under the Indian Self-Determination Act
      (P.L. 93-638 seq.) as a Tribal Organization for the purpose of contracting with the Indian Health
      Service for the provision of Headquarters and Area Office Functions. Twenty tribes authorize the
      CRIHB/IHS to contract for comprehensive health care services. See Appendix E for a list of the
      names and addresses of Tribal health clinics.

      Additional information about CRIHB can be obtained on the organization website at the following
      address: http://www.crihb.org

      Low Income Health Program

      Eligible governmental entities may apply for federal funding to implement a Low Income Health
      Program (“LIHP”). This program is authorized by Chapter 723, Statutes of 2010 (Assembly Bill
      342, Welfare and Institutions Code Sections 15909-15915, and is approved under California’s
      section 1115(a) Medicaid Demonstration, “Bridge to Reform” (“Demonstration”).

      The Demonstration that is effective November 1, 2010 through October 31, 2015, authorizes a
      combination of uncapped and restricted levels of federal funds for the LIHP. The funding will be
      used to expand health care coverage to eligible low-income adults who are aged 19-64 and with
      family incomes at or below 200% of the Federal Poverty Level. Those eligible adults with family
      incomes above 133% of the FPL must be uninsured. The LIHP is effective from November 1,
      2010 through December 31, 2013 at which time the LIHP enrollees will become eligible for the
      Medi-Cal program or the State Health Insurance Exchange. The LIHP is a voluntary local
      program and the non –federal share of the federal reimbursement for health care services in the


                                                   12
      program must be provided by local, non-federal funds. There will be no State General Funds
      monies provided for this program.

      The Federal Centers for Medicaid and Medicare Services conveyed that the CRIHB, Inc. has the
      authority to limit the target population to American Indians and Alaska Natives. According to
      Federal statute, an “Indian Managed Care Entity” may restrict its enrollment to Indians in the
      same manner as Indian health programs may restrict the delivery of services to Indians.
      Importantly, in a letter dated January 22, 2010, from Cindy Mann, Director, Federal Center for
      Medicaid and State Operations, CMS stated its guidance that the American Recovery and
      Reinvestment Act of 2009, Public Law 111-5, Section 5006 allows tribal entities to use 100%
      federal money to match with 100% federal money to fund the LIHP. CRIHB has received a grant
      from the Blue Shield of California Foundation to fund start-up activities of the LIHP. Further
      information on the LIHP can be obtained from the website of the California Department of Health
      Care Services (CDHCS) at the following internet address:
      http://www.dhcs.ca.gov/provgovpart/Pages/lihp.aspx

2.2   PURPOSE

      CRIHB, on behalf of its member health clinics, intends to participate as a Low Income Health
      Program. Through Memoranda of Agreements and other protocols with each member health
      clinic, CRIHB has the legal authority to bind the clinics together in a Low Income Health Program.

      CRIHB is currently working to meet the deliverable requirements established by the California
      Department of Health Care Services (CDHCS) to qualify as a Low Income Health Program. In
      addition to documentation of an adequate provider network to ensure the provision of covered
      services, deliverables include, but are not limited to, policies and procedures for credentialing and
      recredentialing providers, utilization management, enrollment and eligibility, care coordination,
      cultural competency, appointment scheduling, and hearings and appeals process. Those
      deliverables will be submitted to the CDHCS on a flow basis.

      Tribal health clinics (See Appendix E) are found throughout California. These currently serve
      80,000 thousand tribal members annually through a wide variety of health care and social
      programs. Tribal health clinics have professional services agreements primary care physicians
      and mid-level practitioners as well as some specialty physicians. In addition, health clinics have
      contracts with additional specialty physicians and other health care providers, including hospitals,
      in the areas they serve. In some cases, health clinics will need an augmentation of their provider
      networks to meet the requirements of the LIHP.

      Tribal health clinics will serve as the exclusive sources of primary care and medical home for
      LIHP eligibles. These clinics will also be responsible for authorizing in writing any medically
      necessary physician specialty care. In some limited cases, specialty care will be offered at the
      clinic. However, in the majority of cases, specialty care will have to be obtained from community
      physicians. Separate from this RFP, CRIHB is arranging for a statewide network of specialty
      physicians to be available for referrals made by the clinics for services not available at the clinics.

      CRIHB estimates that over the course of this project, approximately 2,000 current and new
      patients of services at Tribal Health Clinics will be determined eligible for the LIHP. The CRIHB
      LIHP will have no cost-sharing in the form of premiums, deductibles, co-payments, or co-
      insurance.

      When the Federal Affordable Care Act is implemented on January 1, 2014, the Low Income
      Health Program will cease and LIHP eligibles will transition to full Medicaid eligibility. CRIHB

                                                    13
        plans to advocate strongly that the Medicaid patients who use health care services at Tribal
        Health Programs should have access to Medicaid services through a plan especially designed to
        meet their needs regardless where in California these patients reside.

2.3     SCOPE OF TPA SERVICES

        The scope of claims processing and adjudication, utilization management, and other
        administrative services for CRIHB’s Low Income Health Program are set forth in the section 2.3.1
        below. CRIHB will directly perform certain administrative services that are typically purchased
        from a TPA. Those services, which are excluded from this RFP, are identified in Section 2.3.2

2.3.1   INCLUDED TPA SERVICES

        A.     Plan Documents

               Maintain a master file of plan documents, member service guides, service authorization
               and claims forms, LIHP contract between CRIHB and the California Department of Health
               Care Services, claims administration policies and guidelines, changes in plan benefits,
               and any other material needed to properly administer claims in accordance with the
               provisions of the plan applicable state and federal law and the LIHP contract.

        B.     Eligibility Verification

               Receive and maintain a file of CRIHB LIHP eligibles for the purposes set forth in the
               Scope of Services, including claims processing and verifying eligibility for participating
               providers. CRIHB or its designee will transmit an eligibility file electronically to the TPA
               every two weeks in a mutually agreed format. When requested by health care providers,
               the TPA will provide eligibility verification.

        C.     Claims-Related Forms and Correspondence

               Design, print, deliver, and periodically update any forms and form letters used in
               connection with claims processing at the TPA’s expense. CRIHB reserves the right to
               approve and disapprove the use of all forms and form letters. The forms required include,
               but are not limited to:

               1.      Explanations of Benefits (EOB) – shall clearly show the billed charge, the allowed
                       amount, and the amount the California Foundation for Medical Care (CFMC) PPO
                       Provider is expected to adjust off and indicates affiliation with the CFMC.

               2. Claims correspondence

               3. Claim denials.

        D.     Claims Processing and Adjudication

               1.      Maintain accurate and complete records/files, for claims received, processed, and
                       adjudicated on behalf of CRIHB and LIHP eligibles and any and all
                       correspondence related to those claims, either received from or issued to health
                       care providers.


                                                    14
     2.    Receive and maintain authorizations issued by providers at Tribal Health Clinics
           for physician specialty care.

     3.    Review and examine claims (bills, invoices, and statements) received from
           physicians, clinics, hospitals, laboratory, and any other in-network or out-of-
           network provider who has delivered covered services to CRIHB LIHP eligibles.

     4.    Determine reasonableness of charges.

     5.    Process and adjudicate all appropriate claims as determined by the provisions of
           CRIHB LIHP documents and administrative policies, fee/reimbursement schedules
           established and provided by the CRIHB contracted provider network and other
           schedules as may be provided by CRIHB. For claims incurred outside of the
           CRIHB provider network, determine and pay the lesser of any reimbursement
           rates required by the CRIHB LIHP contract with the California Department of
           Health Care Services (See Appendix F) or reasonable and customary charges for
           that geographic area. Make timely updates to fee schedules and conversion
           factors, as necessary.

     6.    Accept and process claims in compliance with HIPAA rules for Standard
           Transactions.

     7.    Forward electronically claims pending payment to the California Foundation for
           Medical Care for “repricing” and final determination of claims payable amounts.

     8.    To the extent that CRIHB is financially responsible, pay providers within thirty (30)
           days of receipt of a complete claim and correct claims.

     9.    Prepare/issue checks and itemized Explanation of Benefits forms to providers.

     10.   Contact providers by mail and by phone within thirty (30) days of receipt of any
           claim which is not complete or payable providing to the provider a description of
           any needed information and/or the specific reasons for the denial and the
           procedure for a review of the suspension or denial.

E.   Claims Adjustments and Appeals

     1.    Have a policy and procedure to address claims appeals and grievances.

     2.    Any claim appeal or adjustment for a CFMC PPO Provider will be referred to
           CFMC. CFMC will coordinate (a) A timely peer review determination; and (b)
           documentation of due process in any subsequent appeal of an adverse review
           decision. No claim from a CFMC PPO Provider will be adjusted for medical
           necessity or other reasons without peer review and the availability of appeal,
           through the organization sponsoring the local panel of CFMC PPO Providers.

     3.    Be responsible to resolve claims appeals and grievances in accordance with the
           LIHP contract requirements and report monthly to CRIHB regarding the number,
           type, and resolutions or status of claims grievances received.

     4.    Final determination of adjustment of a claim will rest and remain with the TPA.
           Such final determinations are subject to retrospective review by CRIHB.

                                         15
F.   Customer Service to Providers

     1.      Provide professional, courteous, and timely responses to telephone, written, in
             person inquiries and complaints from all sources. Such inquiries may include
             eligibility information, claims status and payment, service authorizations, benefit
             coverage, and related business from providers, including Tribal Health clinics, and
             CRIHB staff. Maintain a written log of inquiries made to TPA in regard to CRIHB-
             LIHP business, noting date, source of inquiry and nature of inquiry (e.g. eligibility
             verification, claims, benefits, etc.).

     2.      Establish mailing address for filing claims correspondence. Maintain electronic
             claims processing systems in compliance with HIPAA requirements for Standard
             Transactions.

     3.      Furnish a toll-free telephone number for incoming customer service calls staffed
             during normal business hours.

G.   Prescription Drug Data

     Use best efforts to integrate the database from the claims it processes on behalf of the
     CRIHB LIHP with the prescription drug data reported by CRIHB’s Pharmacy Benefit
     Management service provider to produce a unified LIHP utilization database.

H.   Special Care Management and Coordination

     Provide the care management services of a registered nurse/case manager (or a
     contracted case management agency) for chronic or catastrophic injuries/illnesses, when
     approved by CRIHB. Services should include arranging hospital/home visits to assess
     patient needs, making arrangements for necessary home health care/special equipment
     rentals, and coordination of patient care needs with physician, family and patient. Provide
     timely case management reports to CRIHB. Prior to initiating case management for a
     CRIHB LIHP eligible, TPA shall obtain CRIHB approval in writing.

I.   Utilization Management Services

     1.      Provide hospital pre-admission certification when medically necessary; hospital
             concurrent utilization review; hospital length of stay monitoring; discharge planning
             services; preauthorization when requested by providers and plan participants, etc.

     2.      Provide CRIHB with written copies of all TPA UM policies and procedures for the
             purpose of demonstrating to CRIHB and to the CA Department of Health Care
             Services the adequacy of professional review and the capability of the UM function
             under the CRIHB LIHP.

J.   Third Party Tort Liability

     Pursue liens in favor of CRIHB for sums of money recovered by a LIHP eligible in
     connection with any illness, injury, disease, or other condition for which a third party may
     be liable to the extent of the benefit payments made by CRIHB.

K.   Overpayments

                                           16
     Collect any claims overpayments or other incorrect payments and remit to CRIHB
     according to CRIHB’s accounting policies. Any outstanding overpayments/incorrect
     payments shall be reported to CRIHB on a quarterly basis.

L.   Recoupment of Disqualified Certified Public Expenditures

     Collect from providers any payments which CRIHB informs Proponent have been
     disqualified by the Federal or State Government as Certified Public Expenditures.

M.   Management Reports

     Provide reports/information pertaining to the program which may be required by CRIHB,
     its auditor, actuary, legal counsel, or consultant and assist with the preparation and filling
     of any reports required by law. This will include, but is not limited to:

     1.     Register/report of claim payments and other claim data for each payment cycle.

     2.     Monthly statistics report to include:

            a. Number of claims by service benefit category (hospital, surgery, physician,
               non-physician, mental health, etc.)
            b. Dollar amount claimed
            c. Number of claims
            d. Total allowable charges
            e. Amount paid by line of coverage

            All reports must be provided on a monthly and year-to-date basis by service
            benefit category each month.

     3.     Claims history will include dates received, date pended, additional information
            requested, additional information received, date processed, date paid, and/or date
            denied.

     4.     Quarterly reports will include the following:

            a. Hospitals Inpatient/Outpatient Services: Claims activity reports which will
               provide information regarding gross charges, allowed amounts and percentage
               of savings by hospital for inpatient and outpatient services.
            b. Physicians and Ancillary Providers: Claims activity reports which will provide
               information regarding gross charges, allowed amounts, and percentage of
               savings by provider by zip code for professional services.

     5.     Special Case Management and Care Coordination

            a. For cases approved by CRIHB, provide written special case management and
               care coordination activity reports to the patient’s primary care provider.
            b. When cases are open, make a monthly Special Case Management and Care
               Coordination activity report in a format mutually agreeable to TPA and CRIHB.

     6.     Utilization Management Services


                                           17
            a. Make regular case specific service authorization requests, modifications and
               denials to the requesting provider and to the Tribal health clinic.
            b. Make monthly utilization management activity reports to CRIHB in a format
               mutually agreeable to TPA and CRIHB.

     7.     Special reports may be requested by CRIHB regarding:

            a.   Claims Lags
            b.   High-dollar claims
            c.   Tort liability involved claims
            d.   Results of internal TPA compliance reports and corrective action plans
            e.   Utilization Management

N.   Internal Controls

     1.     Apply industry standard internal claim control systems/procedures necessary for
            the effective implementation of the plan.

     2.     Audit all hospital claims where payment exceeds $25,000.

     3.     Monitor other claims on random and periodic basis.

     4.     Agree to maintain the security and confidentiality of all medical, financial, and
            patient information, guaranteeing HIPAA requirements are met in all areas of
            operation.

     5.     Maintain a compliance program that adheres to professionally recognized
            standards, including compliance with applicable federal and state laws and
            regulations.

O.   Financial Services

     Follow the banking requirements of CRIHB, such as establishing, maintaining, and
     reconciling an interest-bearing, checking account with appropriate deposit and transfer
     procedures for the payment of claims; or make other claims payment arrangements which
     are acceptable to CRIHB. The TPA will maintain check registries and will provide a
     monthly check register to CRIHB.

     1.     Accumulate data, prepare, and mail 1099 forms for all providers of service who
            are paid during the calendar year, as required by the Internal Revenue Code.

     2.     Provide any required federal or state financial or tax reports.

     3.     Provide appropriate information and documentation to CRIHB’s designated auditor
            when requested.

     4.     Provide electronic funds transfer capability between the TPA and selected
            participating CRIHB LIHP providers.

P.   Administrative Expenses


                                          18
     The selected Proponent will be expected to bear the cost of:

     1.     Installing any necessary administrative systems.

     2.     Installing any necessary data to administer claims for the CRIHB LIHP

     3.     Transferring records and systems to any succeeding Administrator at the
            termination of the contract.

     4.     Proponent’s administrative staff, all office space, supplies, forms, standard
            management reports, telephone expenses, postage, computer hardware/software,
            and other equipment/supplies necessary for claims handling.

Q.   Communication between CRIHB and the TPA

     1.     Participate in standing quarterly telephone meetings with CRIHB executive staff.

     2.     Respond to business calls from CRIHB staff within 24 hours.

     3.     Notify CRIHB of claim backlogs on the 15th day of each month of operations.

     4.     Provide prompt updates on business, legal and regulatory changes to which the
            TPA is subject that could affect the LIHP

     5.     Notify CRIHB within 1 (one) business day of any egregious claims and/or claims
            action and any potential litigation that may directly or indirectly affect the business
            arrangement between CRIHB and the Proponent.

     6.     Provide reasonable assistance, such as cost calculations for benefit changes,
            benefit adequacy studies, etc, when requested for proposed plan design changes.

     7.     Certain matters of significance to CRIHB’s business must be called to CRIHB’s
            attention within 24 hours of discovery, for example including atypical claims
            processing back logs, compromising claims system problems, large
            overpayments, reportable breaches of LIHP eligibles identifiable health information
            as defined by federal and state law, etc.)

     8.     Notify CRIHB of any Breaches as defined by HIPAA, the HITECH Act, and
            California’s law.

R.   Recordkeeping and Inspection Rights

     1.     The TPA shall agree to make all of its books and records, pertaining to the goods
            and services furnished under the terms of the TPA Agreement, available for
            inspection, examination or copying:

            a. By CRIHB, DHCS, Department of Health and Human Services (DHHS), and
               Department of Justice (DOJ).
            b. At all reasonable times at the Subcontractor's place of business or at such
               other mutually agreeable location in California.
            c. In a form maintained in accordance with the general standards applicable to
               such book or record keeping.

                                           19
                       d. For a term of at least five (5) years from the close of the current fiscal year in
                          which the date of service occurred; in which the record or data was created or
                          applied; and for which the financial record was created.
                       e. Including all enrollment, expenditure, and utilization data, including encounter
                          data, for a period of at least five (5)years.
                       f. HIPAA related policies and procedures shall be retained for a period of six (6)
                          years following revision or retirement.

               2.      At the conclusion of the agreement, provide to CRIHB a copy of all records
                       maintained on CRIHB’s behalf in usable formats which meet industry standards for
                       the turnover of a client’s business.

               3.      Obtain CRIHB’s written approval prior to the destruction of any records related to
                       CRIHB business.

2.3.2   EXCLUDED TPA SERVICES

        A.     Identification Cards

               CRIHB will retain responsibility to prepare, print and distribute LIHP Identification Cards.

        B.     LIHP Member Guides

               CRIHB will retain responsibility to prepare, print, and distribute member information
               guides and materials.

        C.     Customer Service To LIHP Applicants and Eligibles

               CRIHB will retain responsibility to respond to all inquiries from LIHP applicants and
               eligibles for information concerning eligibility, benefits, restrictions, limitations, exclusions,
               grievances and appeals, and the action taken on any prior authorization requests.

2.4     OTHER REQUIREMENTS

        The Supplemental Questionnaire (Appendix D) is a requirement of this Request for Proposal and
        must be submitted in order for the proposal to be considered responsive.

3.0.    PROPOSAL GUIDELINES, CONTENT AND FORMAT

        CRIHB uses a qualifications-based selection process in obtaining these services. In order for the
        CRIHB to properly evaluate the Proponents’ qualification to perform this work, the proposals shall
        include, as a minimum, the following information:

        A.     Evidence of the Proponent’s ability to be responsive to this project in regard to timeliness
               and expertise, including availability of staff proposed to be assigned.

        B.     The Proponents are encouraged to expand on the Scope of Work to demonstrate their
               expertise. Evaluation of the proposals will be based on qualifications, the experience of
               staff proposed to be assigned to the project, references and thoroughness of the
               proponent’s response to the Scope of Services.

        C.     Such additional information that the Proponent may feel would be pertinent to assist

                                                       20
               CRIHB in making its final decision.

        D.     Please submit one (1) original and FOUR (4) copies of your proposal/qualifications. One
               of the copies should be unbound to allow us to reproduce your proposal, as needed.

3.0.1   COVER LETTER

        Submit a letter on your company letterhead addressing the proposal and format. The letter
        should be signed by an officer of the firm authorized to bind the firm to all comments made in the
        proposal, and shall include the name, address, phone number and e-mail address of the
        person(s) to contact who will be authorized to represent your firm.

3.0.2   MINIMUM EXPERIENCE QUALIFICATIONS SUMMARY

        Provide a statement of professional experience and ability.

3.0.3   MANAGEMENT/METHOD OF OPERATION

        Provide detailed description outlining your firm’s approach to provide the service. Highlight
        innovative ideas your firm may have to provide to CRIHB and describe in detail your procedures
        and management techniques.

3.0.4   REFERENCES

        See Supplemental Questionnaire (Appendix D).

3.0.5   FINANCIAL STATEMENT

        A full and detailed presentation of the true condition of the proponent’s assets, liabilities and net
        worth. The report should include a balance sheet and income statement. If the proponent is a
        new partnership or joint venture, individual financial statements must be submitted for each
        general partner or joint venture thereof. If firm is a publicly held corporation, the most current
        annual report should be submitted.

3.0.6   CORPORATE STRUCTURE, ORGANIZATION

        Describe how your firm is organized, noting major divisions and any parent/holding companies,
        as well as brief history of the firm and all personnel potentially to be involved in the project.
        Designate the Principal in Charge and other key personnel. Include résumés. Also provide a
        description of the experience your firm has had with similar projects.

3.0.7   PROPOSAL FEE (UNDER SEPARATE COVER)

        Provide detailed basic fee structure and breakdown of any other charges related to your firm’s
        proposal. Finalist’s fee structure may be subject to negotiation.

3.0.8   The proposal must be submitted, typewritten on 8½” X 11” white paper and must be bound in a
        secure manner.

3.0.9   Material and data not specifically requested for consideration, but which the proponent wishes to
        submit must not appear with the Proposal Form, but may appear only in an “Additional Data”
        section. This has specific reference to the following types of data:

                                                      21
       A.      Generalized narrative of supplementary information; and
       B.      Supplementary graphic material

3.0.10 All proposals must be signed with the full name of the proponent, if an individual; by an
       authorized general partner, if a partnership; or by an authorized officer, if a corporation.

3.0.11 When proposals are signed by an agent other than an officer of a corporation or a member of a
       general partnership, a power of attorney authorizing the signature must be submitted with the
       proposal.

3.0.12 If the proposal is submitted by a partnership or joint venture, the Statement of Personal History
       attached to the Proposal Form must be completed by each general partner or joint venture
       thereof. If the proposal is submitted by a corporation, the Statement must be completed by each
       principal officer of said corporation.

3.0.13 The original proposal must have wet ink signatures. Modification to a proposal after the
       proposal submittal deadline will not be accepted by CRIHB.

3.1    PROPOSAL EVALUATION PROCEDURE AND CRITERIA

       CRIHB is interested in selecting a qualified firm with the ability to provide a Third Party
       Administrator for a Low Income Health Program Claims, Utilization Management, and
       Administrative Services. A key component for the successful firm will be the ability to meet
       CRIHB‘s performance desires while minimizing the cost.

       The Evaluation Panel will consist of CRIHB staff and any other person(s) designated by CRIHB.
       Following review of the proposals, the Panel may invite one or more proponents to make an oral
       presentation. During these presentations, the proponent will be allowed to present such
       information as may be appropriate in order that the Panel can effectively and objectively analyze
       all materials and documentation submitted as part of the proposals.

       Each firm must be represented by an individual who will be the prime contact person to CRIHB
       and any other individuals whom the firm may select. The highest-rated proposal(s) will then be
       further scrutinized through financial analysis and reference checks.

       To that end, the Panel will evaluate the proposals based on, but not limited to, the following
       criteria:

       A.      Proponent’s ability to provide all services as outlined in the Scope of Services;

       B.      Related experience with similar projects, company background and personnel
               qualifications;

       C.      Proponent’s Fee Schedule: completed and signed (under separate sealed cover);

       D.      Proponent’s Agreement;

       E.      Non-Collusion Affidavit;

       F.      References;


                                                     22
      G.     Any other criteria as may be defined by CRIHB.

3.2   PROPOSAL DEVELOPMENT COSTS

      The cost of preparing and submitting a proposal is the sole responsibility of the proponent and
      shall not be chargeable in any manner to CRIHB.

3.3   PROPONENT CONTACT

      Proponent shall provide the name, address, e-mail address and telephone number of an
      individual in their organization to whom notices and inquiries by CRIHB should be directed as
      part of this proposal.

3.4   CRIHB’S USE OF PROPOSAL MATERIAL

      All material submitted in or with the proposal shall become the property of CRIHB, unless it
      is clearly marked as proprietary information. CRIHB reserves the right to use any ideas
      presented in the proposals, without compensation paid to the Firm. Selection or rejection of the
      proposal shall not affect this right.

3.5   REJECTION OF PROPOSAL

      CRIHB reserves the right to reject any and all proposals submitted and to request additional
      information from the Proponent. The award will be made to the firm which, in the opinion of
      CRIHB, is best qualified.




                                                  23
                                                 APPENDIX A

                                         PROPONENT’S AGREEMENT

In submitting this proposal, as herein described, the proponent agrees that:

1.     They have carefully examined the Scope of Work and all other provisions of this document and
       understand the meaning, intent and requirements of same.

2.     They will enter into contract negotiations and furnish the services specified.

3.     They have signed and notarized the attached Non-Collusion Affidavit form, whether individual,
       corporate or partnership. Must be ‘A Jurat’ notarization.

4.     They have reviewed all clarifications/questions/answers on CRIHB’s website at
       http://www.crihb.org.

5.     Confidentiality: Successful Proponent hereby acknowledges that information provided by CRIHB
       is personal and confidential and shall not be used for any purpose other than the original intent
       outlined in the Request for Proposal. Breach of confidentiality shall be just cause for immediate
       termination of contract agreement.




FIRM                                                 ADDRESS



SIGNED BY                                            TITLE OR AGENCY



TELEPHONE NO. / FAX NO.                              DATE



EMAIL ADDRESS




                                                    24
                                                              APPENDIX B
NON-COLLUSION--No. 1 AFFIDAVIT FOR INDIVIDUAL PROPONENT
STATE OF CALIFORNIA,                                   )ss.
County of                                              )
                                        (insert)
                                                                                                                  being first duly sworn,
deposes and says: That on behalf of any person not named herein; that said Bidder has not colluded, conspired, connived or agreed, directly
or indirectly with, or induced or solicited any other bid or person, firm or corporation to put in a sham bid, or that such other person, firm or
corporation shall or should refrain from bidding; and has not in any manner sought by collusion to secure to themselves any advantage over
or against the California Rural Indian Health Board, Inc., or any person interested in said improvement, or over any other Bidder.


                                                                                  (Signature Individual Bidder)
Subscribed and sworn to (or affirmed) before me on this               day of                                              , 20
by                                                   , proved to me on the basis of satisfactory evidence to be the person(s) who appeared
before me.

Seal

Signature

No. 2                                     AFFIDAVIT FOR CORPORATION PROPONENT
STATE OF CALIFORNIA,                                                  )ss.
County of                                                             )
                                        (insert)

being first duly sworn, deposes and says: That they are the                                                     of                                  a
induced or solicited any other bid or person, firm or corporation to put in a sham bid, or that such other person, firm or corporation shall or
should refrain from bidding; and has not in any manner sought by collusion to secure to themselves any advantage over or against the
California Rural Indian Health Board, Inc., or any person interested in said improvement, or over any other Bidder.

                                                                                  (Signature Corporation Bidder)
Subscribed and sworn to (or affirmed) before me on this               day of                                             , 20
by                                              , proved to me on the basis of satisfactory evidence to be the person(s) who appeared
before me.

Seal

Signature

No. 3              AFFIDAVIT FOR FIRM, ASSOCIATION, OR CO-PARTNERSHIP
STATE OF CALIFORNIA,                                    )ss.
County of                                               )
                                        (insert)
                                                                                                                                                    ,
interest or behalf of any person not named herein; that said Bidder has not colluded, conspired, connived or agreed, directly or indirectly
with, or induced or solicited any other bid or person, firm or corporation shall or should refrain from proposing; and has not in any manner
sought by collusion to secure to themselves any advantage over or against the California Rural Indian Health Board, Inc., or any person
interested in said improvement, or over any other Bidder.

                                                                                  (Signature)


                                                                                (Signature)
Subscribed and sworn to (or affirmed) before me on this               day of                                              , 20
by                                                   , proved to me on the basis of satisfactory evidence to be the person(s) who appeared
before me.

Seal

Signature

                                                                      25
                                                          APPENDIX C

                                           INSURANCE REQUIREMENTS
                                       PROPONENT CORPORATION SERVICES

INSURANCE Throughout the life of this Contract, the Proponent shall pay for and maintain in full force and effect
with an insurance company(s) (Company) admitted by the California Insurance Commissioner to do business in
the State of California and rated not less than “A: VII” in Best Insurance Key Rating Guide, the following policies of
insurance:

A. COMMERCIAL OR COMPREHENSIVE GENERAL LIABILITY insurance which shall include Contractual
   Liability, Products and Completed Operations coverages, Bodily Injury and Property Damage (including Fire
   Legal Liability) Liability insurance with combined single limits of not less than $2,000,000 per occurrence, and
   if written on an Aggregate basis, $4,000,000 Aggregate limit (CG 0001).

B. COMMERCIAL (BUSINESS) AUTOMOBILE LIABILITY insurance, endorsed for “any auto” with combined
   single limits of liability of not less than $1,000,000 each occurrence. (CA 0001)

C. PROFESSIONAL ERRORS AND OMISSIONS, Not less than $1,000,000 per Claim./$2,000,000 Aggr. (5 yr.
   discovery and reporting tail period coverage). Certificate of Insurance only required.

D. WORKERS’ COMPENSATION Insurance as required under the California Labor Code, and Employers Liability
   Insurance with limits not less than $1,000,000 per accident/injury/disease.

Deductibles and Self-Insured Retention
Any deductibles or self-insured retention must be declared to and approved by CRIHB.

Other Insurance Provisions

The Policy (s) shall also provide the following:

    a)   The Commercial General Liability and Automobile Liability insurance shall be written on ISO approved occurrence
         form (see item 1 and 2 above) and endorsed to name: CRIHB, Inc. ISO form CG 20 37 10
         01 edition shall be used as the Additional Insured Endorsement. This form must be used with either ISO form CG 20
         10 10 01, or CG 20 33 10 01 (or earlier editions of these forms).

    b)   For any claims related to this project, the Proponent’s insurance coverage shall be primary insurance as respects
         CRIHB, its officers, representatives, agents, employees and volunteers. Any coverage maintained by CRIHB shall be
         excess of the Proponent’s insurance and shall not contribute with it. Policy shall waive right of recovery (waiver of
         subrogation) against CRIHB.

    c)   Each insurance policy required by this clause shall be endorsed to state that coverage shall not be cancelled by either
         party, except after thirty (30) days’ prior to written notice by certified mail, return receipt requested, has been given to
         CRIHB. Further, the thirty (30) day notice shall be unrestricted, except for workers’ compensation, which shall permit
         ten (10) days advance notice. The Insurer shall provide CRIHB with notification of any cancellation, major change,
         modification or reduction in coverage.

    d)   Regardless of these contract minimum insurance requirements, the Proponent and its insurer shall agree to commit
         the Proponent’s full policy limits and these minimum requirements shall not restrict the Proponent’s liability or
         coverage limit obligations.

    e)   Coverage shall not extend to any indemnity coverage for the active negligence of the additional insured in any case
         where an agreement to indemnify the additional insured would be invalid under Subdivision (b) of Section 2782 of the
         California Civil Code.

    f)   The Company shall furnish CRIHB with the Certificates and Endorsements for all required insurance, prior to
         CRIHB’s, execution of the Agreement and start of work.

    g)   Proper Address for Mailing Certificates, Endorsements and Notices shall be:

    h)   Upon notification of receipt by CRIHB of a Notice of Cancellation, major change, modification, or reduction in
         coverage, the Contractor shall immediately file with CRIHB a certified copy of the required new or renewal policy and
         certificates for such policy.


                                                                 26
Any variation from the above contract requirements shall only be considered by and be subject to approval by the
CRIHB’s RFP Officer.

If at any time during the life of the Contract or any extension, the Proponent fails to maintain the required insurance in full force
and effect, all work under the Contract shall be discontinued immediately, and all payments due or that may become due to the
Proponent shall be withheld until acceptable replacement coverage notice is received by CRIHB. Any failure to maintain the
required insurance shall be sufficient cause for CRIHB to terminate this Contract. In the event of insurance cancellation,
CRIHB reserves the right to purchase insurance or insure (or self-insure) for the above-required coverages, at the Proponent’s
full expense.

If the Proponent should subcontract all or any portion of the work to be performed in this contract, the Consultant shall cover
the Sub-contractor, and/or require each Sub-contractor to adhere to all subparagraphs of these Insurance Requirements
section. Similarly, any Cancellation, Lapse, Reduction in Coverage, or Change of Subcontractors insurance shall have the
same impact as described above.




                                                                 27
                                            APPENDIX D
                       CALIFORNIA RURAL INDIAN HEALTH BOARD, INC.
                              REQUEST FOR PROPOSAL
                     LOW INCOME HEALTH PLAN CLAIMS, UTILIZATION
                      MANAGEMENT AND ADMINISTRATIVE SERVICES

                                   Supplemental Questionnaire

1. TELL US ABOUT YOUR ORGANIZATION

  Describe your company’s overall experience and qualifications, especially in the public sector,
  and include the following information:

        Indicate how long your organization has administered health plans and how many
         clients you currently service in the public sector.
        Indicate whether your organization has been known by any other names within the last
         ten years.
        Is your organization anticipating any expansion or reorganization within the next year? If yes,
         please explain.
        Provide an outline/organizational chart for your company, listing departments and
         departmental responsibilities.
        List any characteristics of your organization that you feel distinguishes you from other
         health plan administrators.

  Note: Additional information may be requested from your firm if it’s selected as a finalist.

2. STAFF QUALIFICATIONS

  Please provide the names and attach resumes for key personnel who would be assigned to manage
  and/or work directly with this account.

3. CLAIMS ADMINISTRATION SYSTEM

  Please describe the software system used for claims adjudication and benefit/eligibility
  administration. Please indicate what functions, if any, are not automated and whether your
  programming/computer support is outsourced or managed internally. Your response should
  address the following:

        Electronic claim submission capabilities
        Identification and recovery of duplicate payments
        Identification of unbundled claims
        Identification and recovery of Third Party Liability claims (subrogation only)
        Transmit and receive electronic eligibility data
        Electronic funds transfer capability

4. CLAIMS PROCESSING FACILITY

  Please indicate the physical location(s) of the claims processing facility that would handle/process
  claims for this group, and the customer service office that would service this account. From what
  address will claims correspondence be mailed? From what address will reimbursement checks be
  mailed?


                                                   28
5. STATISTICS FOR CLAIMS PROCESSING

  For the claims processing facility designated in question number 4, please provide the following
  information:

        What is your average turnaround time for processing claims?
        Approximately how many claims are processed annually?
        Indicate the total number of employees that work at this location.
        Indicate how many employees were hired during 2011.

6. UTILIZATION MANAGEMENT and MEDICAL REVEW

  Please describe your experience performing utilization review and the professional review systems in
  place.

        What is the organization of the utilization management and medical review function?
        What professional background is required to review services for medical necessity?
        Do you have a full time medical professional on staff to supervise non-physician staff?
        What criteria are used to make medical necessity determinations? How frequently are these
         criteria updated?
        Do you have a professional committee(s) to provide input to the medical review system and
         suggest improvements?
        When your staff needs to seek the assistance of a specialist in a particular medical field, what
         do they do?
        How do you notify the physician and the patient when a service request requiring
         authorization is modified or denied?
        Describe your policies and procedures for service prior authorization, as well as concurrent
         and retrospective review.

7. CLAIMS ADMINISTRATION STAFF

  Briefly discuss your proposed approach to the claims administration for this group and include
  the following information in your response.

        Number of employees you anticipate will be necessary to manage/process claims.
        Do you anticipate hiring additional personnel in order to provide the claims processing
         services for this account?

9. PROVIDER SERVICES STAFF

  Briefly discuss your proposed approach to providing customer service to participating providers.

9. PERIODIC/ADHOC REPORTS

  Provide samples of regular claim reports (detailed claims experience, eligibility, statistical and
  financial reports) lag reports, potential tort liability case reports, large claim/case management
  reports, etc., provided to your clients on a regular basis, and indicate the frequency they are issued.
  Also, please provide examples of ad hoc reports that can be produced and indicate in what format
  these reports can be produced (i.e. Excel, PDF, etc.)

10. SAMPLES OF EXPLANATION OF BENEFITS AND FORM LETTERS

  Provide samples of your Explanation of Benefits and any form letters issued in connection with

                                                   29
   claims and eligibility administration

11. INTERNAL AUDITING AND QUALITY CONTROL

   Describe your internal auditing procedures and policies and the quality control measures in place to
   ensure financial and procedural accuracy in health plan claims administration.

   Describe your corporate compliance program in place to assure compliance with applicable laws
   and regulations.

12. DISASTER RECOVERY PROGRAM

   Describe your disaster recovery program should the health plan records/data maintained in your
   system be adversely affected by earthquake, fire, flood, or another catastrophic event.

13. HIPAA PRIVACY AND SECURITY COMPLIANCE

   Describe any automated systems, and policies/procedures in place to ensure compliance with
   HIPAA Privacy and Security rules, the HITECH Act and California privacy and security
   regulations.

14. COMPATABILITY WITH OTHER DATA SYSTEMS

   CRIHB plans to interface with the CALWINS system to receive LIHP eligibility data. CALWINS
   complies with HIPAA standards. Confirm that your company has the ability to receive electronic
   enrollment/eligibility data in HIPAA compliant files. CRIHB plans to enter into an agreement with the
   California Foundation for Medical Care (“CFMC”) for provider network services. The TPA must
   submit provider claims to CFMC for “re-pricing.” Confirm that your company has experience
   transmitting claims to CFMC for re-pricing and receiving re-priced claims from CFMC. Confirm that
   your company can produce claims transaction files to the California Department of Health Care
   Services according to specifications set forth by the Department.

15. CLIENT REFERENCES – Current Clients:

   Please list three accounts to which you currently provide third party administrative services, and
   include the following information for each:

          Client Name
          Contact Person
          Address
          Telephone Number

16. PROVIDER NETWORK ASSOCIATIONS

   The core set of participating providers is comprised of 11 Tribal Health Programs which are
   members of the CRIHB LIHP. (See Appendix E, List of Tribal Health Clinics)

          Please indicate to what extent, if any, your company has worked with Tribal Health Programs
           in providing TPA services to other clients.
          Please indicate whether your company has worked with California Foundation for Medical
           Care network for other group health plans.

17. IMPLEMENTATION PLAN
    Describe the implementation plan, including timeline to meet the CRIHB start-up date of July 1, 2012.
                                                   30
                                  APPENDIX E: TRIBAL HEALTH PROGRAMS
        TRIBAL HEALTH PROGRAM                     ADDRESS                    CITY         ZIP    COUNTY SERVED
                                                                                         CODE
Greenville
Greenville Rancheria THP                        410 Main Street            Greenville    95947       Plumas
Greenville Rancheria THP                    1425 Montgomery Road           Red Bluff     96080       Tehama


Karuk
Karuk Tribal Health Clinic                   64236 Second Avenue          Happy Camp     96039       Siskiyou
Karuk Tribal Health Clinic                     39051 Highway 96             Orleans      95556      Humboldt
Karuk Tribal Health Clinic                   1519 South Oregon St            Yreka       96097       Siskiyou


MACT Health Board Inc-Admin
Sonora Indian Health Clinic                     13975 Mono Way              Sonora       95370      Tuolumne
Jackson Rancheria Health Center              12150 New York Ranch           Jackson      95642       Amador
San Andreas Community Clinic              265 West Saint Charles Street   San Andreas    95249      Calaveras
Mariposa Indian Health Center                  5192 Hospital Road          Mariposa      95338      Mariposa


Mathiesen Chicken Ranch Rancheria              18144 Secco Street         Jamestown      95327      Tuolumne


Redding Rancheria                           3184 Churn Creek Road           Redding      96002       Shasta


Shingle Springs Rancheria                      5168 Honpie Road            Placerville   95667      El Dorado


Sonoma County Indian Health Project
Manchester/Point Arena Clinic                24 Mamie Laiwa Drive         Point Arena    95468      Mendocino
Sonoma County Indian Health                   144 Stony Point Road        Santa Rosa     95401       Sonoma


Toiyabe Indian Health Project
Bishop Clinic                                    52 Tu Su Lane              Bishop       93514        Mono
Lone Pine Clinic                              1150 Goodwin Road            Lone Pine     93545        Inyo
Camp Antelope (Temp Closed)                 73 Camp Antelope Road          Coleville     96107        Mono


Tule River Reservation                      380 N Reservation Road         Porterville   93257       Tulare


UIHS
Howonquet Health Center                      501 North Indian Road        Smith River    95567      Del Norte
                                                                           Crescent
Elk Valley Health Center                      2298 Norris Avenue             City        95531      Del Norte
Klamath Health Clinic                         241 Salmon Avenue             Klamath      95548      Del Norte
                                           Weitchpec Route, Libby Nix
Weitchpec Health Clinic                        Community Center             Hoopa        95546      Humboldt
Potawot Health Village                          1600 Weeot Way               Arcata      95521      Humboldt
Fortuna Health Center                           940 Main Street             Fortuna      95540      Humboldt


Warner Mountain                             132 Mee Thee-Uh Road          Fort Bidwell   96112       Modoc




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APPENDIX F: EXPECTED TERMS OF THE LIHP AGREEMENT BETWEEN CRIHB AND THE
CALIFORNIA DEPARTMENT OF HEALTH CARE SERVICES




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