RFQ No. 4019000014

METROPOLITAN TRANSIT AUTHORITY

REQUEST FOR QUALIFICATIONS

FOR

PRE-AUTHORIZATION FOR WORKERS COMPENSATION MEDICAL SERVICES

On An ‘As Needed’ Basis

METRO REQUEST FOR QUALIFICATIONS NO. 4019000014

METRO requests Statements of Qualifications (SOQs) from qualified consultant teams to perform the services noted above. Advanced experience in this area is mandatory.

SOQs are not to exceed five (5) typed pages, and must be accompanied by an organization chart and Standard Form 330, Part I (prime) and Part II (each subconsultant/subcontractor).

Please submit seven (7) copies of the SOQ materials cited above.

METRO must receive the Statement of Qualifications no later than

2:00 p.m. local time, December 12, 2018

Attention: Fatima Rubio, Contract Services AssistantRFQ No.: 4019000014METROPOLITAN TRANSIT AUTHORITYProcurement DivisionProcurement Office Plan Room1900 Main St., Houston, Texas 77002

Please contact Valencia Eaton with any questions about this RFQ.

PHONE: (713) 739-4878 EMAIL: valencia.eaton@ridemetro.org (No collect calls accepted)

METRO FUNDING 100%

RFQ No. 4019000014

TABLE OF CONTENTS

SECTION I - BIDDING/PROPOSING REQUIREMENTS AND INSTRUCTIONS.......................................................................................1 REQUEST FOR QUALIFICATIONS SUMMARY...........................................................................................................................2 STATEMENT OF QUALIFICATIONS (SOQ) REQUIREMENTS...................................................................................................3 EVALUATION CRITERIA..............................................................................................................................................................4 EVALUATION / SOURCE SELECTION........................................................................................................................................5 SMALL BUSINESS AND DISADVANTAGED BUSINESS ENTERPRISE PROGRAMS..............................................................6 SUMMARY OF STATEMENT OF QUALIFICATIONS (SOQ) FORMS SUBMISSION..................................................................7 INSTRUCTIONS TO SOQ RESPONDERS...................................................................................................................................

SECTION II - EXHIBITS.............................................................................................................................................................................1 EXHIBIT A SCOPE OF SERVICES...........................................................................................................................................2 EXHIBIT B CERTIFICATION OF RESTRICTIONS ON LOBBYING.........................................................................................3 EXHIBIT C DEBARMENT AND SUSPENSION FORM.............................................................................................................4 EXHIBIT D SMALL BUSINESS FORMS...................................................................................................................................

Form 1 CONTRACTOR UTLIZATION PLAN FORM.........................................................................................30Form 2 BUSINESS ASSURANCE STATEMENT..............................................................................................34Form 3 SUBCONTRACTOR/SUPPLIER LETTER OF INTENT........................................................................35Form 4 CONTRACTOR UTILIZATION PLAN PLEDGE....................................................................................36

5 EXHIBIT E CODE OF ETHICS OF THE METROPOLITAN TRANSIT AUTHORITY................................................................

IMPORTANT – Notice to ProposerAll responses to this solicitation must be labeled as indicated below and delivered or mailed to the following address:

Metropolitan Transit Authority Upper Left Corner of Envelope Must Indicate: Procurement Division Bidder/Contractor Name and AddressPlan Room, 2nd Floor1900 Main Street Lower Left Corner of Envelope Must Indicate:Houston, Texas 77002 Solicitation Number

Due DateDue TimeSolicitation Title

RFQ No. 4019000014

SECTION I – STATEMENT OF QUALIFICATIONS SUBMISSION REQUIREMENTS AND INSTRUCTIONS

1 REQUEST FOR QUALIFICATIONS SUMMARY

RFQ NO.: 4019000014 RFQ ISSUE DATE: 11/05/2018

PROJECT NAME: Pre-Authorization for Workers Compensation Medical Services

For: Professional Pre-Authorization for Workers Compensation Medical Services on an ‘As Needed’ Basis

ISSUED BY: Metropolitan Transit Authority of Harris County (METRO)

METRO Procurement Web site: https://www.ridemetroapp.org/procurement/

RECEIPT DATE/TIME/LOCATION of STATEMENT OF QUALIFICATIONS (SOQs): SOQs will be received until 2:00 p.m. local time on December 12, 2018 at the METRO Procurement Office Plan Room, 2nd floor, 1900 Main St., Houston, Texas 77002. Responders are to submit an original and seven (7) copies in a sealed envelope bearing the name and address of the Responder and the identification ‘Request for Qualifications No. 4019000014.’ SOQs received will not be opened publicly. See additional submission requirements below in Article 2.

A PRE-SUBMITTAL BRIEFING will be held at 2:00 November 15, 2018 Procurement Conference Room, 1900 Main St., Houston, Texas, 77002. All interested firms are encouraged to attend.

OBLIGATION: This Request for Qualifications does not obligate the Metropolitan Transit Authority to award a contract, or to pay any costs incurred in the preparation or submittal of any response.

PERFORMANCE PERIOD: The performance period for a contract resulting from this solicitation will be Three years and Two (2) One (1) year option years. Services thereunder will be utilized on an ‘as needed’ basis.

REGISTRATION ON PROCUREMENT WEBSITE: All Responders ARE ENCOURAGED register on METRO's procurement website at https://www.ridemetroapp.org/procurement/ to ensure that they receive the latest solicitations and updates via their registered e-mail address.

REPRODUCTION: All forms contained in this solicitation may be reproduced if more space is needed due to the number of subcontractors or suppliers to be submitted with the SOQ or for any other reason.

WRITTEN QUESTIONS: Written questions will be accepted until 2:00 p.m. November 19, 2018. Submit questions to Valencia Eaton email, valencia.eaton@ridemetro.org.

2 STATEMENT OF QUALIFICATIONS (SOQ) REQUIREMENTS

A. Respondents wishing to be considered for award of Pre-authorization for Workers Compensation Medical Services as set forth in this RFQ, must submit an original and seven (7) copies of an SOQ, not-to-exceed five (5) typewritten pages each, using no smaller than 9 point, Arial font; double-sided pages), describing its interest and the qualifications of the team and key personnel. Do not include a cover letter with the SOQ. METRO forms to be submitted that are included as Exhibits herein are not counted in the five pages.

B. The SOQ must include an organization chart (not counted in the five pages) and identify all team participants and all proposed subconsultants and/or subcontractors, and their responsibilities.

C. A copy of a single Standard Form 330, Part I for the prime, as well as copies of a Standard Form 330, Part II for each and every firm identified as a team participant in the SOQ (not counted in the five pages), must accompany each copy of the SOQ. Firms listed as small businesses must have certification documentation attached (not counted in the five pages) that demonstrates their small business status. In Section E of the Form 330, resumes shall be organized in alphabetical order by last name and irrespective of firm affiliation. Link to Standard Form 330: https://www.gsa.gov/forms-library/architect-engineer-qualifications .

3 EVALUATION CRITERIA

RFQ No. 4019000014

In keeping with the core requirements listed above, the SOQ shall address the following METRO criteria and shall be supported by the Standard Form 330. The evaluation criteria are identified with relative weights adding up to 100 points. Submittals should be organized under the following headings and should address each topic to demonstrate the Respondent’s qualifications and ability to perform the Work. Please provide the following:

FACTORRELATIVE IMPORTANCE

1. QUALIFICATIONS/EXPERIENCE OF PERSONNEL: 20 points

The Respondent shall demonstrate their qualifications to perform the Work, including:

The Proposers shall provide the professional qualifications and experience of theproposed project manager and other key personnel assigned to the project

Demonstrate and discuss the direct qualifications and experience of the individual relevant toMETRO’S Requirement.

Provide dedicated registered nurse (RN) with appropriate certification for initial review Provide assigned Medical Review Officer (MRO) certification and current training. A second MRO

certified and licensed must be available for reconsideration submissions. Reference function(s) to be performed by each individual, including backup or

contingency personnel.

2. QUALIFICATIONS/EXPERIENCE OF FIRM: 25 points  

The Respondent shall:

Provide introduction of firm, including, primary business experience and length of time in business. Demonstrate history and experience relevant to METRO’s needs, including a description of direct

experience on projects of similar size, scope and complexity. Demonstrate relevant experience working with federal, state, local governmental or mass transit

agencies. Demonstrate clients represented in the past five (5) years in which similar services were

provided, as well as three (3) current clients with name and telephone number ofcontact person and duration of project.

Provide certification by the Texas Division of Workers Compensation.

3. PROJECT MANAGEMENT; STRUCTURE METHODOLOGY: 25 points  

The Respondent shall:

l Demonstrate familiarity with the Specifications of the Texas Department of Insurance, Division of Workers Compensation (TXCOMP) regarding certification of medical services.

Provide a brief overview of the key issues and the approach to this project as detailed in Scope of Services.

Demonstrate clear understanding of the rules concerning preauthorization and shall defer to the rule of the law in addressing any requests for preauthorization. Should requests not meet the criteria for review under the law the proposer shall notify the requestor and adjuster of the same.

Maintain all documents associated with preauthorization in accordance with the record retention guidelines outlined by the Texas Division of Workers Compensation. Additionally, the documentation must be formatted (in Adobe, Word, Excel) to easily transfer to the Division of Workers’ Compensation and METRO upon request.

4. CUSTOMER SERVICES: 30 points  

The Respondent must be a high tier performer certified and in good standing with the Division of Workers Compensation.

RFQ No. 4019000014

The Respondent must demonstrate its online tool to review any requests and precertification decisions real time. The portal should be web based, be serviced by the proposer and available within and outside business hours.

The Respondent shall demonstrate it can provide a high level of professionalism when communicating with medical providers, employees and METRO staff.

The Respondent shall provide a dedicated contact number and fax line and demonstrate the ability to be available from  8 am to 5 pm Monday through Friday with exception of Federal holidays. 

The Respondent shall demonstrate the ability to provide a preliminary decision within 24 hours and must finalize the decision within 3 working days.

The Respondent shall demonstrate its ability to ensure that reconsiderations are finalized within the time allotted by the law.

4 EVALUATION / SOURCE SELECTION

A. Selection of a firm to provide the services required herein may be made by an Evaluation Committee. The Evaluation Committee will determine the most qualified firm(s) through validation of factors in described above and oral presentations, if necessary. If the decision is made to conduct oral presentations, oral presentations will be made accordingly.

B. The evaluation process may include the participation of an Oral Presentation Committee; an Executive Selection Committee, or a Board Selection Committee. The participation of the Executive Selection Committee or the Board Selection Committee may occur at the beginning of the evaluation process, foregoing an Evaluation Committee of staff members all together, or to become involved after the Evaluation Committee has made an initial shortlist. Board members may elect to participate as scoring members or non-scoring observers in any of these committees.

C. Following the evaluation of qualification submittals for Pre-authorization for Workers Compensation, METRO may, at its sole discretion:

1. Invite a short list of qualified Respondents to participate in oral interviews;

2. Take no further action; or

3. Modify (expand or reduce) the Scope of Services, Attachment A, and issue a Request for Submittal based upon the modified scope.

5 SMALL BUSINESS AND DISADVANTAGED BUSINESS ENTERPRISE PROGRAMS

A. The Metropolitan Transit Authority of Harris County, Texas (METRO) has implemented a Small Business Enterprise Program, hereinafter referred to as the Program, for small businesses attempting to provide goods and/or services as prime Contractors to METRO or as subcontractors to other prime Contractors to METRO. It is the policy of METRO to promote equal opportunity and nondiscrimination in all of its procurement matters in accordance with state and federal law. The Program seeks to provide METRO-certified Small Businesses (SBE) and Texas Unified Certification Program (TUCP)-certified Disadvantaged Businesses Enterprises (DBE) a full and fair opportunity to participate in METRO projects through race-gender neutral means. The Small Business Enterprise Program shall not be used to discriminate against any person or company or group of persons or companies because of race, color, religion, sex, age, disability or national or ethnic origin. Each bidder, proposer, Contractor and subcontractor shall comply with this nondiscrimination requirement.

B. The Small Business Enterprise Program is a separate program from METRO’s Disadvantaged Business Enterprise (DBE) Program which is administered by the federal government and applies to federally funded projects. METRO’s Small Business and Disadvantaged Business Enterprise Programs can be found at https://www.ridemetro.org/Pages/SB-FormsTemplates.aspx

C. Nothing in the Small Business or Disadvantaged Business Enterprise Programs should be construed to give a bidder or proposer a property interest in a Submittal or contract prior to the Board of Directors’ award of the contract and compliance with all statutory and legal requirements.

D. METRO has established a Small Business Participation goal for this solicitation. The Small Business

RFQ No. 4019000014

Participation goal may be satisfied by utilizing METRO-certified Small Businesses or TUCP-certified Disadvantaged business enterprises or a combination of both. All references to Small Businesses include Disadvantaged Businesses. The Small Business Participation goal is:

0%

RESPONDERS WHO FAIL TO COMMIT TO THE SMALL BUSINESS CONTRACT GOAL WILL BE DEEMED NONRESPONSIVE AND NO FURTHER CONSIDERATION WILL BE GIVEN TO THEIR SUBMISSION.

E. Small Business Goal Commitment for a Small Business Participation goal listed in above item D

1. If a Small Business Participation goal is established in item D above , bidders/proposers who fail to commit to the Small Business Participation goal will be deemed nonresponsive and no further consideration will be given to their Submittal.

2. Non-certified Small Business or TUCP Disadvantaged Business Enterprise primes must subcontract at a minimum the Small Business Participation goal percentage to certified Small Business firms, TUCP Disadvantaged Business Enterprise firms or a combination of both in order to satisfy the Small Business Participation goal requirement.

3. The performance of a METRO-certified Small Business or TUCP Disadvantaged Business Enterprise prime may satisfy the Small Business Participation goal requirement if:

a) The SBE/DBE prime self-performs at a minimum the Small Business Participation goal percentage

Example: Small Business Participation goal is 35%The SBE/DBE prime self-performs 35%The prime has satisfied the 35% Small Business Participation goal

b) The SBE/DBE prime combined with a SBE/DBE subcontractor performs at a minimum the Small Business Participation goal percentage

Example: Small Business Participation goal is 40%The SBE/DBE prime self-performs 35%SBE/DBE subcontractor performs 5%The prime has satisfied the 40% Small Business Participation goal

c) The SBE/DBE prime cannot self-perform 100% of the contract. The prime must subcontract to SBE/DBEs and/or non-SBE/DBEs at a minimum the Small Business Participation goal percentage

Example: Small Business Participation goal is 35%SBE/DBE prime self-performs 65%Subcontractors (certified and/or non-certified) perform 35%The prime has satisfied the 35% Small Business Participation goal

d) Joint venture Contractors with SBE/DBE partners will count towards the Small Business Participation goal only for the percentage of the SBE/DBE partner.

Example: Joint venture1 - Non-SBE/DBE partner @ 50% of joint venture1 - SBE/DBE partner @ 50% of joint ventureJoint venturer is performing 30% of the contract = 15% Small Business participation

e) Joint venturers and their partners are prohibited from submitting as a prime and as a subcontractor on the same submission.

Example: Joint venturer submits as a primeJoint venture partners are listed as subcontractors on the same submissionJoint venturers and partners are prohibited from submitting in this way

RFQ No. 4019000014

f) All prime Contractors, whether SBE/DBE or non-SBE/DBE, must always self-perform at a minimum thirty percent (30%) of the contract regardless of the Small Business Participation goal percentage

g) Bidders/proposers are prohibited from multiple submissions of Submittals, i.e. submitting as a prime Contractor in one submission and as a subcontractor in another submission for the same project. Such multiple submissions may result in the disqualification of all submissions where the bidder/proposer is listed.

h) Agreements between a bidder/proposer and a Small Business Enterprise or Disadvantaged Business Enterprise in which the SBE or DBE promises not to provide subcontracting quotations to other bidders/proposers shall be prohibited.

i) SBEs and DBEs are limited to submitting as subcontractors on only four (4) Submittals for the same project. Failure to adhere to this four (4) Submittal limit may result in the disqualification of the offending SBE or DBE from all Submittals.

F. Required Small Business Documents

1. Contractor Utilization Plan

a) IT IS MANDATORY that every bidder or proposer submit a Contractor's Utilization Plan (the ‘Plan’) when submitting a Submittal or response to request for qualifications, whether or not a Small Business Participation goal has been established.

b) The bidder/proposer must use this form to identify all subcontractors with whom the bidder/proposer intends to contract, specifying the agreed price and/or percentage to be paid each subcontractor for such work, and certifying the contract items and parts thereof to be performed by each subcontractor. Only percentages of Contract Work Effort are to be indicated when responding to RFQ/RFP submissions, as pricing is determined later in the procurement process.

c) If applicable , the Plan should set forth how the Small Business Participation goal for the proposed project is to be met. The Plan will be used by METRO as a factor in evaluating whether a bidder/proposer has complied with the requirements of the Program to satisfy the Small Business Participation goal.

d) If the Small Business participation submitted by the bidder/proposer does not meet an established Small Business Participation goal, if any, the bidder/proposer will be deemed non-responsive and will not be considered for contract award.

e) Failure to submit a complete Plan for a contract with a Small Business Participation goal will result in Submittal being deemed non-responsive and will not be considered for contract award.

f) When a Small Business Participation goal has been established , the Small Business Participation goal, the Contractor shall adhere to the Plan submitted unless a waiver is received from the Office of Small Business. Any changes in the Plan regarding the proposed use of certified subcontractors in discharging the contract duties must be approved by the Office of Small Business. The approval of the Office of Small Business will not be unreasonably withheld upon a showing of good cause to make the change.

g) When adding a certified subcontractor to the Plan with a Small Business Participation goal, the Contractor must submit a copy of the subcontract agreement to the Office of Small Business within fifteen (15) days of receiving approval from the Office of Small Business.

h) The Contractor Utilization Plan must include the following:

1) A simple, straight-forward statement outlining subcontractor participation regardless of certification, inclusive of scope, responsibilities and percentage of work.

2) Materials and supplies shall be counted towards the small business goal as follows:

RFQ No. 4019000014

i. 100 percent of the cost of materials or supplies purchased from a small business manufacturer can be applied towards the Small Business Participation goal of a Contract. A manufacturer is defined as a firm that operates or maintains a factory or establishment that produces, on the premises, the materials, supplies, articles, or equipment of the general character described by the scope and/or specifications of the contract.

ii. Sixty percent of the cost of materials or supplies purchased from a small business regular dealer can be applied towards the Small Business Participation goal of a Contract. A regular dealer is defined as a firm that owns, operates, or maintains a store, warehouse, or other establishment in which the materials, supplies, articles or equipment of the general character described by the scope and/or specifications of the contract are bought, kept in stock, and regularly sold or leased to the public in the usual course of business.

3) Copies of documents demonstrating that each Small Business team member is acceptably certified as either a METRO-certified Small Business or TUCP-certified Disadvantaged Business Enterprise, and verifying that such certification is current as of the date of submission.

i. METRO accepts the following certifications:

SBE - Metropolitan Transit Authority of Harris County (METRO) DBE - City of Houston/Texas Unified Certification Program (TUCP) DBE - City of Austin DBE – Corpus Christi Regional Transportation Authority DBE – North Central Texas Regional Certification Agency DBE – South Central Texas Regional Certification Agency Texas Department of Transportation (DOT) approved DBE certification

ii. METRO does not accept the following certifications:

State of Texas HUB (Historically Underutilized Business) Minority Business Enterprise only Women Business Enterprise only City of Houston Small Business certification only

iii. If a proposer/bidder submits plans to add a firm as part of its small business participation that is not yet certified as referenced above, that firm must be either METRO Small Business- or TUCP Disadvantaged Business Enterprise-certified prior to the Submittal date. Firms certified after the Submittal date will not be counted towards the commitment. Additional Small Business certification information and forms may be found at METRO’s website: www.ridemetro.org under Small Business.’

4) When requested, a timeline for performance by subcontractors.

5) Signature of the bidder/proposer

2. Business Assurance Statement (BAS)a) Bidders/proposers are required to submit an executed Business Assurance Statement form

with their Submittal when a Small Business Participation goal has been established .

b) Bidders/proposers must enter their Small Business Participation goal commitment. This includes the SBE/DBE prime’s participation if applicable.

c) Bidders/proposers must enter into agreements with the subcontractors listed on the Plan

d) Bidders/proposers must include the BAS Clauses in their subcontractor agreements

3. Letter of Intent (LOI)

a) Bidders/proposers are required to submit a Letter of Intent form for all subcontractors when a

RFQ No. 4019000014

Small Business Participation goal has been established.

b) The Letters of Intent must be executed by the prime and the subcontractor

4. Contractor Utilization Plan Pledge (Pledge)

a) Bidders/proposers are required to submit an executed Pledge form with their Submittal when a Small Business Participation goal has been established.

b) Bidders/proposers must pledge prompt payment to ALL subcontractors

c) Bidders/proposers must affirm adherence to METRO’s Nondiscrimination Mandate.

d) When applicable, bidders/proposers must pledge prompt payment of retainage

e) Bidders/proposers must include the Pledge Clauses in their subcontractor agreements

G. Incentives Utilizing Small Businesses

1. Fees for Solicitation Documents. Submitters making a valid bid and participating in the Program will receive a refund for up to seven (7) sets of documents purchased from METRO.

2. Bid Security/Bond. A bid security will no longer be required except for federally funded construction solicitations exceeding $100,000.

3. METRO's Incentives. METRO may utilize other incentives, as set forth in the request for Submittal, as it determines appropriate.

H. METRO encourages Contractors to use financial institutions owned and controlled by socially and economically disadvantaged individuals. A listing of such institutions may be found at www.federalreserve.gov/releases/mob/current/default.htm

6 SUMMARY OF STATEMENT OF QUALIFICATIONS (SOQ) FORMS SUBMISSION

Insert requested information and sign and date where indicated.

SUBMIT WITH COMPLETED SUBMITTAL

Statement of Qualifications, responses to Evaluation Criteria Section I, No. 2 AOrganization Chart Section I, No. 2 B Standard Form 330, Part I (prime) and Part II(For each subconsultant/subcontractor) Section I, No. 2 C‘Certification of Restrictions on Lobbying’ form Section II, Exhibit B‘Contractor’s Utilization Plan’ form Section XI, Exhibit C, Form 1

SUBMIT IF A SMALL BUSINESS GOAL IS ESTABLISHED‘Business Assurance Statement’ form Section XI, Exhibit C, Form 2‘Subcontractor/Supplier Letter of Intent’ form Section XI, Exhibit C, Form 3‘Contractor’s Utilization Plan Pledge’ form Section XI, Exhibit C, Form 4Acceptable certification documentation

SUBMIT ONLY IF APPLICABLEEvidence of attainment of proper license or permit, if special licensing or permitting is required by federal, state or local law or ordinance.

7 INSTRUCTIONS TO SOQ RESPONDERS

A. APPROVAL OF CONTRACT

If required by the METRO Procurement Manual, award of a Contract evolving from this solicitation shall be

RFQ No. 4019000014

contingent upon the prior receipt of written approval from the METRO Board of Directors. No contractual agreement shall be binding on METRO until this approval has been obtained. It shall be the responsibility of firms responding to this solicitation to monitor Board award decisions. All persons and/or entities responding to this Solicitation hereby acknowledge the contract award requirement enumerated in this Paragraph. Anticipated Board Items are posted on METRO’s web site at: https://www.ridemetro.org/Pages/BoardMeetingsAndNotices.aspx

Public Notice of Solicitation Results

The anticipated METRO Board meeting month for approval of a contract resulting from this solicitation will be forthcoming. It is the responsibility of the bidder to check METRO’s website for notices on the specific dates for METRO Board meetings. All bidders of this Solicitation and METRO hereby agree that this provision shall serve as the minimum required action by the bidder toward exercising due diligence in obtaining the results of this Solicitation. The requirement of approval by the METRO Board of Directors for any particular solicitation is dependent upon several factors. However, all bidders shall be required to check the METRO web site regarding whether or not the solicitation associated with their bid requires approval by the METRO Board of Directors. All persons and/or entities responding to this Solicitation hereby acknowledge the Public Notice of Solicitation Results enumerated in the Paragraph. METRO Board meeting notices are posted on METRO’s web site at:https://www.ridemetro.org/Pages/BoardMeetingsAndNotices.aspx

B. CERTIFICATION

By submitting a SOQ in response to this announcement, a Respondent certifies that neither its firm nor any of its principals is presently debarred, suspended, proposed for debarment, declared ineligible, or excluded from participation in this procurement process by any federal department or agency. Further, if any of the aforementioned situations occurs during the course of the procurement, the Respondent is required to inform METRO thereof.

C. CONFLICTS DISCLOSURE

Vendors doing business with METRO or seeking to do business with METRO are required to file a completed questionnaire (FORM CIQ) disclosing the vendor’s affiliations or business relationship with any Board Member, local government officer (or his or her family member). Form CIQ is available on METRO’s web site at https://www.ridemetro.org/Pages/ConflictsDisclosure.aspx.

D. PREPARATION OF STATEMENTS OF QUALIFICATIONS (SOQs)

In an effort to promote greater use of recycled and environmentally preferable products and minimize waste, all Submittals submitted should comply with the following:

1. All submittals and copies should be printed on recycled paper with a minimum post-consumer content of thirty percent (30%) or on tree-free paper (i.e., paper made from raw materials other than trees, such as kenaf). All Submittals should note the level of recycled content contained in the paper being used.

2. Unless absolutely necessary, all Submittals and copies should minimize or eliminate the use of non-recyclable or non-reusable materials, such as plastic report covers, plastic dividers, vinyl sleeves and bindings. Three-ringed binders, glued materials, paper clips and staples are acceptable.

3. Responders should submit materials in a format that allows for easy removal and recycling of paper materials.

4. Responders are encouraged to use other products that contain recycled content in their Submittal documents. Such products may include, but not limited to, folders, binders, paper clips, discs, envelopes, boxes, etc. Where appropriate, responders may wish to note which products in their Submittal are made with recycled materials.

5. Unnecessary samples, attachments or documents not specifically asked for should not be submitted with the Submittal.

E. PROHIBITION ON LOBBYING

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No Responder shall, directly or indirectly, engage in any conduct (other than the submission of the SOQ or other prescribed submissions and/or presentations before the Evaluation or Selection Committees) to influence any employee of METRO or any member of the Metropolitan Transit Authority Board of Directors concerning the award of a contract as a result of this Solicitation. Violation of this prohibition may result in disqualification of the Bidder or Proposer from further participation in the solicitation for the services or goods sought herein or from participation in future METRO solicitations or contracts. The communication blackout period shall commence from the issue of a solicitation through contract award. The Contract Administrator is the only METRO representative authorized to communicate with firms or their representatives during the blackout period.

F. PROTESTS

1. Any protest of the Request for Qualifications shall be submitted for resolution to the Chief Procurement Officer. Such protest shall be in writing and shall be supported by the information set forth in Chapter 12 of METRO’s Procurement Manual to enable the protest to be considered. A protest will not be considered if it is insufficiently supported or it is not received within the time limits specified herein.

2. A protest based upon terms, conditions or form of a proposed procurement action prior to submission of qualifications, shall be submitted so that it is received by the Chief Procurement Officer no later than five (5) calendar days prior to the specified date for submission of qualifications.

3. For a protest concerning award decision, including evaluations, the initial protest must be received by the Chief Procurement Officer not later than five (5) calendar days after the interested party knows, or through exercise of reasonable diligence should have known, whichever is earlier, of the grounds for the protest.

4. Each protest will be processed in accordance with METRO’s Protest Procedures located in Chapter 12 of METRO’s Procurement Manual. A copy of the procedures will be provided to the protester upon written request to METRO’s Chief Procurement Officer.

5. A written final determination on any protest will be rendered by METRO’s President & Chief Executive Officer and will be provided to the protester as soon as practicable.

6. The protestor must exhaust its administrative remedies by pursuing METRO’s protest procedures to completion prior to appealing METRO’s decision to the FTA.

7. Federal Transit Administration (FTA) Circular 4220.1F, Paragraph 7L, addresses bid protests. A copy of this Paragraph will be provided to the protester upon written request to METRO. Review of a protest by FTA will be limited to a grantee’s failure to have or follow its written protest procedures or its failure to review a complaint or protest or violation of federal law or regulation. An appeal to FTA must be received by the cognizant FTA regional or Headquarters Office within five (5) working days of the date the protester learned or should have learned of any adverse decision by METRO, or other basis of appeal to the FTA. Violations of a specific federal law or regulation will be handled by the complaint process stated with that law or regulation. Alleged violations on other grounds are under the jurisdiction of the appropriate state or local administrative or judicial authorities.

RFQ No. 4019000014

SECTION II – EXHIBITS

1 EXHIBIT A SCOPE OF SERVICES

Pre-Certification of Workers’ Compensation Medical ServicesI. Introduction

The Metropolitan Transit Authority of Harris County (METRO) is a self-insured, self-administered claim operation subscribing to the rules under the Texas Division of Workers’ Compensation. A successful vendor must comply with all rules set forth by the Division, have qualified professional staff and meet all deadlines outlined within. Historically, METRO pre-authorizations are approximately 55 basic reviews, 30 physician reviews of paper work and 5 requiring telephonic conferences per month.

II. Scope of Services

The scope of services outlines METRO’s requirements for a successful partnership and highlights the specifications of the Texas Department of Insurance, Division of Workers Compensation (TXCOMP) regarding certification of medical services. Services shall be performed by persons qualified and where stated in the law certified to complete preauthorization of medical services. The vendor must be knowledgeable with and comply with the following rules under TXCOMP: §134.530. Requirements for Use of the Closed Formulary for Claims Not Subject to Certified Networks, §134.540. Requirements for Use of the Closed Formulary for Claims Subject to Certified Networks, §134.550. Medical Interlocutory Order and §134.600. Preauthorization, Concurrent Utilization Review, and Voluntary Certification of Health Care. The vendor must remain knowledgeable of updates and changes and adopt any amendments of the rules within the states specified timeline.

III. Requirements

In addition to the regulatory requirements noted above, the successful vendor should employ a courteous and professional staff who provides prompt and professional services to METRO. The vendor should have all necessary professionals and resources to timely complete pre-certifications and comply with the Scope of Services. The vendor should be established and with a record of successful performance of pre-certifications for Texas Workers’ Compensation claims.

A. Professional Staff

Staff should meet the needs of METRO and comply with all state requirements. At minimum, the vendor must employ a Medical Director and a Registered Nurse as permanent staff. Additional talent required to fulfill business needs may be under contract; however, the person(s) or vendor(s) utilized must be specified and should provide individual, current curriculum vitae. For providers the curriculum vitae should include a current license number and specify what the physician is certified for. Appropriate certification is required for chiropractors and medical doctors. Registered Nurses must provide evidence of working knowledge of the official disability guidelines adopted by TXCOMP.

B. Online Portal

To ensure that there is a constant flow of information between METRO and the vendor for preauthorization of medical services an online portal with 24-hour access to pending requests and completed reports is required. The portal should have the appropriate security measures to protect sensitive protected health information. The vendor should define its security measures and ensure data is encrypted and securely housed with a backup. Access should require independent user access. The portal should organize the certifications by adjuster but allow the adjuster to easily access team member reports. METRO shall provide a report clearly identifying the adjuster and disputes at a mutually agreeable frequency defined at implementation. The adjuster should have the ability to easily download or forward reports to external users from the portal. Each certification request should be clearly labeled with the claim number, claimant name, date of accident, body part request pertains to and what service the physician is requesting. Preferably the adjuster should have the ability to upload any relevant Division or Plain Language forms as well as leave specific messages for the reviewer that are relevant to the patient. C. Other Communication

The vendor should provide a call center for general inquiries. The vendor must designate a dedicated point

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of contact for METRO. The dedicated point of contact must be available to METRO by phone or email and should respond to requests within 24 hours. A second party should be designated as a backup should the designated point of contact be unavailable. There must be a dedicated fax number and dedicated intake phone number. The vendor should list the contact information for each resource fulfilling the contract requirements.

D. Notification Preferences

METRO is working toward a paperless claims operation and prefers paperless communication whenever possible. The vendor should be open to transfer of documents by SFTP or email. Outside the preferences outlined in the Texas Workers’ Compensation code these are METRO’s preferences:

i. METROPrior to review METRO prefers to be notified of request for surgical procedures by phone. All other certification requests notifications may be sent by email to workerscomp.claims@ridemetro.org. When a certification is complete it should be posted on the portal and a link or email regarding report completion should be sent to the claim adjuster. The content should also enclose any clinical submitted by the medical provider.

ii. Medical Bill Review CompanyThe Medical Bill Review company is STARR Comprehensive Solutions. Certifications should be faxed to STARR at (713) 462-4948.

iii. EmployeeMETRO requests that any plain language notice documentation such as plain language notice 1 or 11 provided to the vendor be enclosed with the completed report sent to the provider.

iv. Plaintiff AttorneyMETRO requests that any plain language notice documentation such as plain language notice 1 or 11 provided to the vendor be enclosed with the completed report sent to the provider.

v. Requesting PhysicianMETRO requests that any plain language notice documentation such as plain language notice 1 or 11 provided to the vendor be enclosed with the completed report sent to the provider.

vi. FacilityMETRO requests that any plain language notice documentation such as plain language notice 1 or 11 provided to the vendor be enclosed with the completed report sent to the provider.

E. Response Times

The code clearly outlines the required response time for a requested service. The vendor should provide their business practices and methodology to meet these requirements.

F. Business Hours

The vendor must have staff on hand to answer calls Monday through Friday excluding federal holidays. Business hours should be Monday through Friday from 8 am to 5 PM central standard time.

G. Billing

The contractor shall provide a monthly itemized billing statement which identifies the claim for which review was performed and which service(s) provided. The invoice should be grouped by claim number and organized by review date. The monthly invoice shall arrive no later than the 15th date of the month. The invoice should contain all services provided in the prior month. The invoice should be accompanied by a copy of the pre-authorization report. In addition to the itemized bill, the vendor shall provide an invoice with summary level information which includes simply the services provided with quantity of each unit and total amount due. The monthly bill should have a unique invoice number for tracking.

IV. DefinitionsA. For this document the following definitions shall apply:

i. “METRO” shall mean Metropolitan Transit Authority of Harris County, Texas. ii. “Contractor” Shall mean the individual, partnership, corporation, organization or association

contracting with METRO to furnish the services defined in this scope.

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iii. “Vendor” shall mean the company providing services that fulfill the requirements of this scope.iv. “TXCOMP” shall mean Texas Workers’ Compensation.

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Exhibit B Rule 134.530-134.600 TXCOMP Rules: http://www.tdi.texas.gov/wc/rules/documents/wcrules.pdf

The provisions of this §134.520 adopted to be effective January 17, 2011, 35 TexReg 11344 (corrected effective date published 36 TexReg 158).

§134.530. Requirements for Use of the Closed Formulary for Claims Not Subject to Certified Networks.

(a) Applicability. The closed formulary applies to all drugs that are prescribed and dispensed for outpatient use for claims not subject to a certified network on or after September 1, 2011 when the date of injury occurred on or after September 1, 2011.

(b) Preauthorization for claims subject to the Division's closed formulary.

(1) Preauthorization is only required for:

(A) drugs identified with a status of "N" in the current edition of the ODG Treatment in Workers' Comp (ODG) / Appendix A, ODG Workers' Compensation Drug Formulary, and any updates;

(B) any compound that contains a drug identified with a status of "N" in the current edition of the ODG Treatment in Workers' Comp (ODG) / Appendix A, ODG Workers' Compensation Drug Formulary, and any updates; and

(C) any investigational or experimental drug for which there is early, developing scientific or clinical evidence demonstrating the potential efficacy of the treatment, but which is not yet broadly accepted as the prevailing standard of care as defined in Labor Code §413.014(a).

(2) When §134.600(p)(12) of this title (relating to Preauthorization, Concurrent Review, and Voluntary Certification of Health Care) conflicts with this section, this section prevails.

(c) Preauthorization of intrathecal drug delivery systems.

(1) An intrathecal drug delivery system requires preauthorization in accordance with §134.600 of this title and the preauthorization request must include the prescribing doctor's drug regime plan of care, and the anticipated dosage or range of dosages for the administration of pain medication.

(2) Refills of an intrathecal drug delivery system with drugs excluded from the closed formulary, which are billed using Healthcare Common Procedure Coding System (HCPCS) Level II J codes and submitted on a CMS-1500 or UB-04 billing form, require preauthorization on an annual basis. Preauthorization for these refills is also required whenever:

(A) the medications, dosage or range of dosages, or the drug regime proposed by the

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prescribing doctor differs from the medications, dosage or range of dosages, or drug regime previously preauthorized by that prescribing doctor; or

(B) there is a change in prescribing doctor.

(d) Treatment guidelines. Except as provided by this subsection, the prescribing of drugs shall be in accordance with §137.100 of this title (relating to Treatment Guidelines), the division's adopted treatment guidelines.

(1) Prescription and nonprescription drugs included in the division's closed formulary and recommended by the division's adopted treatment guidelines may be prescribed and dispensed without preauthorization.

(2) Prescription and nonprescription drugs included in the division's closed formulary that exceed or are not addressed by the division's adopted treatment guidelines may be prescribed and dispensed without preauthorization.

(3) Drugs included in the closed formulary that are prescribed and dispensed without preauthorization are subject to retrospective review of medical necessity and reasonableness of health care by the insurance

carrier in accordance with subsection (g) of this section.

(e) Appeals process for drugs excluded from the closed formulary.

(1) For situations in which the prescribing doctor determines and documents that a drug excluded from the closed formulary is necessary to treat an injured employee's compensable injury and has prescribed the drug, the prescribing doctor, other requestor, or injured employee must request approval of the drug by requesting preauthorization, including reconsideration, in accordance with §134.600 of this title and applicable provisions of Chapter 19 of this title (relating to Agents' Licensing).

(2) If preauthorization is being requested by an injured employee or a requestor other than the prescribing doctor, and the injured employee or other requestor requests a statement of medical necessity, the prescribing doctor shall provide a statement of medical necessity to facilitate the preauthorization submission as set forth in §134.502 of this title (relating to Pharmaceutical Services).

(3) If preauthorization for a drug excluded from the closed formulary is denied, the requestor may submit a request for medical dispute resolution in accordance with §133.308 of this title (relating to MDR by Independent Review Organizations).

(4) In the event of an unreasonable risk of a medical emergency, an interlocutory order may be obtained in accordance with §133.306 of this title (relating to Interlocutory Orders for Medical Benefits) or§134.550 of this title (relating to Medical Interlocutory Order).

(f) Initial pharmaceutical coverage.

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(1) Drugs included in the closed formulary which are prescribed for initial pharmaceutical coverage, in accordance with Labor Code §413.0141, may be dispensed without preauthorization and are not subject to retrospective review of medical necessity.

(2) Drugs excluded from the closed formulary which are prescribed for initial pharmaceutical coverage, in accordance with Labor Code §413.0141, may be dispensed without preauthorization, except as referenced in subsection (b)(1)(C) of this section, and are subject to retrospective review of medical necessity.

(g) Retrospective review. Except as provided in subsection (f)(1) of this section, drugs that do not require preauthorization are subject to retrospective review for medical necessity in accordance with §133.230 of this title (relating to Insurance Carrier Audit of a Medical Bill) and §133.240 of this title (relating to Medical Payments and Denials), and applicable provisions of Chapter 19 of this title.

(1) Health care, including a prescription for a drug, provided in accordance with §137.100 of this title is presumed reasonable as specified in Labor Code §413.017, and is also presumed to be health care reasonably required as defined by Labor Code §401.011(22-a).

(2) In order for an insurance carrier to deny payment subject to a retrospective review for pharmaceutical services that are recommended by the division's adopted treatment guidelines, §137.100 of this title, the denial must be supported by documentation of evidence-based medicine that outweighs the presumption of reasonableness established under Labor Code §413.017.

(3) A prescribing doctor who prescribes pharmaceutical services that exceed, are not recommended, or are not addressed by §137.100 of this title, is required to provide documentation upon request in accordance with §134.500(13) of this title (relating to Definitions) and §134.502(e) and (f) of this title.

The provisions of this §134.530 adopted to be effective January 17, 2011, 35 TexReg 11344 (corrected effective date published 36 TexReg 158).§134.540. Requirements for Use of the Closed Formulary for Claims Subject to Certified Networks.

(a) Applicability. The closed formulary applies to all drugs that are prescribed and dispensed for outpatient use for claims subject to a certified network on or after September 1, 2011 when the date of injury occurred on or after September 1, 2011.

(b) Preauthorization for claims subject to the Division's closed formulary. Preauthorization is only required for:

(1) drugs identified with a status of "N" in the current edition of the ODG Treatment in Workers' Comp (ODG) / Appendix A, ODG Workers' Compensation Drug Formulary, and any updates;

(2) any compound that contains a drug identified with a status of "N" in the current edition of the ODG Treatment in Workers' Comp (ODG) / Appendix A, ODG Workers' Compensation Drug Formulary, and any updates; and

(3) any investigational or experimental drug for which there is early, developing scientific or clinical evidence demonstrating the potential efficacy of the treatment, but which is not yet broadly accepted as the prevailing standard of care as defined in Labor Code §413.014(a).

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(c) Preauthorization of intrathecal drug delivery systems.

(1) An intrathecal drug delivery system requires preauthorization in accordance with the certified network's treatment guidelines and preauthorization requirements pursuant to Insurance Code Chapter 1305 and Chapter 10 of this title (relating to Workers' Compensation Health Care Networks).

(2) Refills of an intrathecal drug delivery system with drugs excluded from the closed formulary, which are billed using Healthcare Common Procedure Coding System (HCPCS) Level II J codes and submitted on a CMS-1500 or UB-04 billing form, require preauthorization on an annual basis. Preauthorization for these refills is also required whenever:

(A) the medications, dosage or range of dosages, or the drug regime proposed by the prescribing doctor differs from the medications dosage or range of dosages, or drug regime previously preauthorized by that prescribing doctor; or

(B) there is a change prescribing doctor.

(d) Treatment guidelines. The prescribing of drugs shall be in accordance with the certified network's treatment guidelines and preauthorization requirements pursuant to Insurance Code Chapter 1305 and Chapter 10 of this title. Drugs included in the closed formulary that are prescribed and dispensed without preauthorization are subject to retrospective review of medical necessity and reasonableness of health care by the insurance carrier in accordance with subsection (f) of this section.

(e) Appeals process for drugs excluded from the closed formulary.

(1) For situations in which the prescribing doctor determines and documents that a drug excluded from the closed formulary is necessary to treat an injured employee's compensable injury and has prescribed the drug, the prescribing doctor, other requestor, or injured employee must request approval of the drug in a specific instance by requesting preauthorization in accordance with the certified network's preauthorization process established pursuant to Chapter 10, Subchapter F of this title (relating to Utilization Review and Retrospective Review) and applicable provisions of Chapter 19 of this title (relating to Agents' Licensing).

(2) If preauthorization is pursued by an injured employee or requestor other than the prescribing doctor, and the injured employee or other requestor requests a statement of medical necessity, the prescribing doctor shall provide a statement of medical necessity to facilitate the preauthorization submission as set forth in §134.502 of this title (relating to Pharmaceutical Services).

(3) If preauthorization for a drug excluded from the closed formulary is denied, the requestor may submit a request for medical dispute resolution in accordance with §133.308 of this title (relating to MDR by Independent Review Organizations).

(4) In the event of an unreasonable risk of a medical emergency, an interlocutory order may be obtained in accordance with §133.306 of this title (relating to Interlocutory Orders for Medical Benefits) or§134.550 of this title (relating to Medical Interlocutory Order).

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(f) Initial pharmaceutical coverage.

(1) Drugs included in the closed formulary which are prescribed for initial pharmaceutical coverage, in accordance with Labor Code §413.0141, may be dispensed without preauthorization and are not subject to retrospective review of medical necessity.

(2) Drugs excluded from the closed formulary which are prescribed for initial pharmaceutical coverage, in accordance with Labor Code §413.0141, may be dispensed without preauthorization and are subject to retrospective review of medical necessity.

(g) Retrospective review. Except as provided in subsection (f)(1) of this section, drugs that do not require preauthorization are subject to retrospective review for medical necessity in accordance with §133.230 of this title (relating to Insurance Carrier Audit of a Medical Bill), §133.240 of this title (relating to Medical Payments and Denials), the Insurance Code, Chapter 1305, applicable provisions of Chapters 10 and 19 of this title.

(1) In order for an insurance carrier to deny payment subject to a retrospective review for pharmaceutical services that fall within the treatment parameters of the certified network's treatment guidelines, the denial must be supported by documentation of evidence-based medicine that outweighs the evidence-basis of the certified network's treatment guidelines.

(2) A prescribing doctor who prescribes pharmaceutical services that exceed, are not recommended, or are not addressed by the certified network's treatment guidelines, is required to provide documentation upon request in accordance with §134.500(13) of this title (relating to Definitions) and §134.502(e) and(f) of this title.

The provisions of this §134.540 adopted to be effective January 17, 2011, 35 TexReg 11344 (corrected effective date published 36 TexReg 158).

§134.550. Medical Interlocutory Order.

(a) The purpose of this section is to provide a prescribing doctor or pharmacy an ability to obtain an medical interlocutory order (MIO) in instances where preauthorization denials of a previously prescribed and dispensed drug(s) excluded from the closed formulary poses an unreasonable risk of a medical emergency as defined in§134.500(7) of this title (relating to Definitions) and Insurance Code §1305.004(a)

(13).

(b) A request for an interlocutory order that does not meet the criteria described by this section may still be requested pursuant to §133.306 of this title (relating to Interlocutory Order for Medical Benefits).

(c) An MIO will be issued if the request for an MIO contains the following information:

(1) injured employee name;

(2) date of birth of injured employee;

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(3) prescribing doctor's name;

(4) name of drug and dosage;

(5) MIO requestor's name (pharmacy or prescribing doctor);

(6) MIO requestor's contact information;

(7) a statement that a preauthorization request for a previously prescribed and dispensed drug(s), which is excluded from the closed formulary, has been denied by the insurance carrier;

(8) a statement that an independent review request has already been submitted to the insurance carrier or the insurance carrier's utilization review agent in accordance with §133.308 of this title (relating to MDR by Independent Review Organizations);

(9) a statement that the preauthorization denial poses an unreasonable risk of a medical emergency as defined in §134.500(7) of this title;

(10) a statement that the potential medical emergency has been documented in the preauthorization process;

(11) a statement that the insurance carrier has been notified that a request for an MIO is being submitted to the division; and

(12) a signature and the following certification by the MIO requestor for paragraphs (7) - (12) of this subsection, "I hereby certify under penalty of law that the previously listed conditions have been met."

(d) A complete request for an MIO under this section shall be processed and approved by the division in accordance with this section. At the discretion of the division, an incomplete request for an MIO under this section may be considered in accordance with this section.

(e) The request for an MIO may be submitted on the designated division form available on the Texas Department of Insurance's website, http://www.tdi.state.tx.us/wc/indexwc.html. In the event the division form is not available, the written request must contain the provisions of subsection (c) of this section.

(f) The MIO requestor shall provide a copy of the MIO request to the insurance carrier, prescribing doctor, injured employee, and dispensing pharmacy, if known, on the date the request for MIO is submitted to the division.

(g) An approved MIO shall be effective retroactively to the date the complete request for an MIO is received by the division.

(h) Notwithstanding §133.308 of this title:

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(1) A request for reconsideration of a preauthorization denial is not required prior to a request for independent review when pursuing an MIO under this section. If a request for reconsideration or an MIO request is not initiated within 15 days from the initial preauthorization denial, then the opportunity to request an MIO under this section does not apply.

(2) If pursuing an MIO after denial of a reconsideration request, a complete MIO request shall be submitted within five working days of the reconsideration denial.

(i) An appeal of the independent review organization (IRO) decision relating to the medical necessity and reasonableness of the drugs contained in the MIO shall be submitted in accordance with §133.308(t) of this title.

(j) The MIO shall continue in effect until the later of:

(1) final adjudication of a medical dispute regarding the medical necessity and reasonableness of the drug contained in the MIO; expiration of the period for a timely appeal; or

(2) agreement of the parties.

(k) Withdrawal by the requestor of a request for medical necessity dispute resolution constitutes acceptance of the preauthorization denial.

(l) A party shall comply with an MIO entered in accordance with this section and the insurance carrier shall reimburse the pharmacy for prescriptions dispensed in accordance with an MIO.

(m) The insurance carrier shall notify the prescribing doctor, injured employee, and the dispensing pharmacy once reimbursement is no longer required in accordance with subsection (j) of this section.

(n) Payments made by insurance carriers pursuant to this section may be eligible for reimbursement from the Subsequent Injury Fund in accordance with Labor Code §410.209 and §413.055, and applicable rules.

(o) A decision issued by an IRO is not an agency or commissioner decision.

(p) A party may seek to reverse or modify an MIO issued under this section if:

(1) a final determination of medical necessity has been rendered; and

(2) the party requests a benefit contested case hearing (CCH) from the division's chief clerk no later than 20 days after the date the IRO decision is sent to the party. A benefit review conference is not a prerequisite to a division CCH under this subsection. Except as provided by this subsection, a division CCH shall be conducted in accordance with Chapters 140 and 142 of this title (relating to Dispute Resolution--General Provisions and Dispute Resolution--Benefit Contested Case Hearing).

(q) The insurance carrier may dispute an interlocutory order entered under this title by filing a written request for a hearing in accordance with Labor Code §413.055 and §148.3 of this title (relating to Requesting a

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Hearing).

The provisions of this §134.550 adopted to be effective January 17, 2011, 35 TexReg 11344 (corrected effective date published 36 TexReg 158).

Intentionally left blank

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Subchapter G - Prospective and Concurrent Review of Health Care

§134.600. Preauthorization, Concurrent Utilization Review, and Voluntary Certification of Health Care

(a) The following words and terms when used in this chapter shall have the following meanings, unless the context clearly indicates otherwise:

(1) Adverse determination: A determination by a utilization review agent made on behalf of a payor that the health care services provided or proposed to be provided to an injured employee are not medically necessary or appropriate. The term does not include a denial of health care services due to the failure to request prospective or concurrent utilization review. An adverse determination does not include a determination that health care services are experimental or investigational.

(2) Ambulatory surgical services: surgical services provided in a facility that operates primarily to provide surgical services to patients who do not require overnight hospital care.

(3) Concurrent utilization review: a form of utilization review for on-going health care listed in subsection(q) of this section for an extension of treatment beyond previously approved health

care listed in subsection (p) of this section.

(4) Diagnostic study: any test used to help establish or exclude the presence of disease/injury in symptomatic individuals. The test may help determine the diagnosis, screen for specific disease/injury, guide the management of an established disease/injury, and formulate a prognosis.

(5) Division exempted program: a Commission on Accreditation of Rehabilitation Facilities (CARF) accredited work conditioning or work hardening program that has requested and been granted an exemption by the division from preauthorization and concurrent utilization review requirements except for those provided by subsections (p)(4) and (q)(2) of this section.

(6) Final adjudication: the commissioner has issued a final decision or order that is no longer subject to appeal by either party.

(7) Outpatient surgical services: surgical services provided in a freestanding surgical center or a hospital outpatient department to patients who do not require overnight hospital care.

(8) Preauthorization: a form of prospective utilization review by a payor or a payor's utilization review agent of health care services proposed to be provided to an injured employee.

(9) Reasonable opportunity: At least one documented good faith attempt to contact the provider of record that provides an opportunity for the provider of record to discuss the services under review with the utilization review agent during normal business hours prior to issuing a prospective, concurrent, or retrospective utilization review adverse determination:

(A) no less than one working day prior to issuing a prospective utilization review adverse determination;

(B) no less than five working days prior to issuing a retrospective utilization review adverse determination; or

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(C) prior to issuing a concurrent or post-stabilization review adverse determination.

(10) Requestor: the health care provider or designated representative, including office staff or a referral health care provider or health care facility that requests preauthorization, concurrent utilization review, or voluntary certification.

(11) Work conditioning and work hardening: return-to-work rehabilitation programs as defined in this chapter.

(b) When division-adopted treatment guidelines conflict with this section, this section prevails.

(c) The insurance carrier is liable for all reasonable and necessary medical costs relating to the health care:

(1) listed in subsection (p) or (q) of this section only when the following situations occur:

(A) an emergency, as defined in Chapter 133 of this title (relating to General Medical Provisions);

(B) preauthorization of any health care listed in subsection (p) of this section that was approved prior to providing the health care;

(C) concurrent utilization review of any health care listed in subsection (q) of this section that was approved prior to providing the health care; or

(D) when ordered by the commissioner;

(2) or per subsection (r) of this section when voluntary certification was requested and payment agreed upon prior to providing the health care for any health care not listed in subsection (p) of this section.

(d) The insurance carrier is not liable under subsection (c)(1)(B) or (C) of this section if there has been a final adjudication that the injury is not compensable or that the health care was provided for a condition unrelated to the compensable injury.

(e) The insurance carrier shall designate accessible direct telephone and facsimile numbers and may designate an electronic transmission address for use by the requestor or injured employee to request preauthorization or concurrent utilization review during normal business hours. The direct number shall be answered or the facsimile or electronic transmission address responded to within the time limits established in subsection (i) of this section. The insurance carrier shall also comply with any additional requirements of §19.2012 of this title (relating to URA's Telephone Access and Procedures for Certain Drug Requests and Post-Stabilization Care).

(f) The requestor or injured employee shall request and obtain preauthorization from the insurance carrier prior to providing or receiving health care listed in subsection (p) of this section. Concurrent utilization review shall be requested prior to the conclusion of the specific number of treatments or period of time preauthorized and approval must be obtained prior to extending the health care listed in subsection (q) of this section. The request for preauthorization or concurrent utilization review shall be sent to the insurance carrier by telephone, facsimile, or electronic transmission and, include the:

(1) name of the injured employee;

(2) specific health care listed in subsection (p) or (q) of this section;

(3) number of specific health care treatments and the specific period of time requested to complete the treatments;

22

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(4) information to substantiate the medical necessity of the health care requested;

(5) accessible telephone and facsimile numbers and may designate an electronic transmission address for use by the insurance carrier;

(6) name of the requestor and requestor's professional license number or national provider identifier, or injured employee's name if the injured employee is requesting preauthorization;

(7) name, professional license number or national provider identifier of the health care provider who will render the health care if different than paragraph (6) of this subsection and if known;

(8) facility name, and the facility's national provider identifier if the proposed health care is to be rendered in a facility; and

(9) estimated date of proposed health care.

(g) A health care provider may submit a request for health care to treat an injury or diagnosis that is not accepted by the insurance carrier in accordance with Labor Code §408.0042.

(1) The request shall be in the form of a treatment plan for a 60 day timeframe.

(2) The insurance carrier shall review requests submitted in accordance with this subsection for both medical necessity and relatedness.

(3) If denying the request, the insurance carrier shall indicate whether it is issuing an adverse determination, and/or whether the denial is based on an unrelated injury or diagnosis in accordance with subsection (m) of this section.

(4) The requestor or injured employee may file an extent of injury dispute upon receipt of an insurance carrier's response which includes a denial due to an unrelated injury or diagnosis, regardless of whether an adverse determination was also issued.

(5) Requests which include a denial due to an unrelated injury or diagnosis may not proceed to medical dispute resolution based on the denial of unrelatedness. However, requests which include the dispute of an adverse determination may proceed to medical dispute resolution for the issue of medical necessity in accordance with subsection (o) of this section.

(h) Except for requests submitted in accordance with subsection (g) of this section, the insurance carrier shall either approve or issue an adverse determination on each request based solely on the medical necessity of the health care required to treat the injury, regardless of:

(1) unresolved issues of compensability, extent of or relatedness to the compensable injury;

(2) the insurance carrier's liability for the injury; or

(3) the fact that the injured employee has reached maximum medical improvement.

(i) The insurance carrier shall contact the requestor or injured employee within the following timeframes by telephone, facsimile, or electronic transmission with the decision to approve the request; issue an adverse determination on a request; or deny a request under subsection (g) of this section because of an unrelated injury or diagnoses as follows:

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(1) three working days of receipt of a request for preauthorization; or

(2) three working days of receipt of a request for concurrent utilization review, except for health care listed in subsection (q)(1) of this section, which is due within one working day of the receipt of the request.

(j) The insurance carrier shall send written notification of the approval of the request, adverse determination on the request, or denial of the request under subsection (g) of this section because of an unrelated injury or diagnosis within one working day of the decision to the:

(1) injured employee;

(2) injured employee's representative; and requestor, if not previously sent by facsimile or electronic transmission.

(k) The insurance carrier's failure to comply with any timeframe requirements of this section shall result in an administrative violation.

(l) The insurance carrier shall not withdraw a preauthorization or concurrent utilization review approval once issued. The approval shall include:

(1) the specific health care;

(2) the approved number of health care treatments and specific period of time to complete the treatments;

(3) a notice of any unresolved dispute regarding the denial of compensability or liability or an unresolved dispute of extent of or relatedness to the compensable injury; and

(4) the insurance carrier's preauthorization approval number that conforms to the standards described in§19.2009(a)(4) of this title (relating to Notice of Determinations Made in Utilization Review).

(m) In accordance with §19.2010 of this title (relating to Requirements Prior to Issuing Adverse Determination), the insurance carrier shall afford the requestor a reasonable opportunity to discuss the clinical basis for the adverse determination prior to issuing the adverse determination. The notice of adverse determination must comply with the requirements of §19.2009 of this title and if preauthorization is denied under Labor Code§408.0042 because the treatment is for an injury or diagnosis unrelated to the compensable

injury the notice must include notification to the injured employee and health care provider of

entitlement to file an extent of injury dispute in accordance with Chapter 141 of this title (relating

to Dispute Resolution--Benefit Review Conference).

(n) The insurance carrier shall not condition an approval or change any elements of the request as listed in subsection (f) of this section, unless the condition or change is mutually agreed to by the health care provider and insurance carrier and is documented.

(o) If the initial response is an adverse determination of preauthorization or concurrent utilization review, the requestor or injured employee may request reconsideration orally or in writing. A request for reconsideration under this section constitutes an appeal for the purposes of §19.2011 of this title (relating to Written Procedures for Appeal of Adverse Determinations).

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(1) The requestor or injured employee may within 30 days of receipt of a written adverse determination request the insurance carrier to reconsider the adverse determination and shall document the reconsideration request.

(2) The insurance carrier shall respond to the request for reconsideration of the adverse determination:

(A) as soon as practicable but not later than the 30th day after receiving a request for reconsideration of an adverse determination of preauthorization; or

(B) within three working days of receipt of a request for reconsideration of an adverse determination of concurrent utilization review, except for health care listed in subsection (q)(1) of this section, which is due within one working day of the receipt of the request.

(3) In addition to the requirements in this section and §19.2011 of this title, the insurance carrier's reconsideration procedures shall include a provision that the period during which the reconsideration is to be completed shall be based on the medical or clinical immediacy of the condition, procedure, or treatment.

(4) In any instance where the insurance carrier is questioning the medical necessity or appropriateness of the health care services prior to the issuance of an adverse determination on the request for reconsideration, the insurance carrier shall comply with the requirements of §19.2010 and §19.2011 of

this title, including the requirement that the insurance carrier afford the requestor a

reasonable opportunity to discuss the proposed health care with a doctor or, in cases of a

dental plan or chiropractic services, with a dentist or chiropractor, respectively.

(5) The requestor or injured employee may appeal the denial of a reconsideration request regarding an adverse determination by filing a dispute in accordance with Labor Code §413.031 and related division rules.

(6) A request for preauthorization for the same health care shall only be resubmitted when the requestor provides objective clinical documentation to support a substantial change in the injured employee's medical condition or that demonstrates that the injured employee has met clinical prerequisites for the requested health care that had not been previously met before submission of the previous request. The insurance carrier shall review the documentation and determine if any substantial change in the injured employee's medical condition has occurred or if all necessary clinical prerequisites have been met. A frivolous resubmission of a preauthorization request for the same health care constitutes an administrative violation.

(p) Non-emergency health care requiring preauthorization includes:

(1) inpatient hospital admissions, including the principal scheduled procedure(s) and the length of stay;

(2) outpatient surgical or ambulatory surgical services as defined in subsection (a) of this section;

(3) spinal surgery;

(4) all work hardening or work conditioning services requested by:

(A) non-exempted work hardening or work conditioning programs; or

(B) division exempted programs if the proposed services exceed or are not addressed by the division's treatment guidelines as described in paragraph (12) of this subsection;

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RFQ No. 4019000014

(5) physical and occupational therapy services, which includes those services listed in the Healthcare Common Procedure Coding System (HCPCS) at the following levels:

(A) Level I code range for Physical Medicine and Rehabilitation, but limited to:

(i) Modalities, both supervised and constant attendance;

(ii) Therapeutic procedures, excluding work hardening and work conditioning;

(iii) Orthotics/Prosthetics Management;

(iv) Other procedures, limited to the unlisted physical medicine and rehabilitation procedure code; and

(B) Level II temporary code(s) for physical and occupational therapy services provided in a home setting;

(C) except for the first six visits of physical or occupational therapy following the evaluation when such treatment is rendered within the first two weeks immediately following:

(i) the date of injury; or

(ii) a surgical intervention previously preauthorized by the insurance carrier;

(6) any investigational or experimental service or device for which there is early, developing scientific or clinical evidence demonstrating the potential efficacy of the treatment, service, or device but that is not yet broadly accepted as the prevailing standard of care;

(7) all psychological testing and psychotherapy, repeat interviews, and biofeedback, except when any service is part of a preauthorized or division exempted return-to-work rehabilitation program;

(8) unless otherwise specified in this subsection, a repeat individual diagnostic study:

(A) with a reimbursement rate of greater than $350 as established in the current Medical Fee Guideline; or

(B) without a reimbursement rate established in the current Medical Fee Guideline;

(9) all durable medical equipment (DME) in excess of $500 billed charges per item (either purchase or expected cumulative rental);

(10) chronic pain management/interdisciplinary pain rehabilitation;

(11) drugs not included in the applicable division formulary;

(12) treatments and services that exceed or are not addressed by the commissioner's adopted treatment guidelines or protocols and are not contained in a treatment plan preauthorized by the insurance carrier. This requirement does not apply to drugs prescribed for claims under §§134.506, 134.530 or 134.540 of this title (relating to Pharmaceutical

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Benefits);

(13) required treatment plans; and

(14) any treatment for an injury or diagnosis that is not accepted by the insurance carrier pursuant to Labor Code §408.0042 and §126.14 of this title (relating to Treating Doctor Examination to Define the Compensable Injury).

(q) The health care requiring concurrent utilization review for an extension for previously approved services includes:

(1) inpatient length of stay;

(2) all work hardening or work conditioning services requested by:

(A) non-exempted work hardening or work conditioning programs; or

(B) division exempted programs if the proposed services exceed or are not addressed by the division's treatment guidelines as described in subsection (p)(12) of this section;

(3) physical and occupational therapy services as referenced in subsection (p)(5) of this section;

(4) investigational or experimental services or use of devices;

(5) chronic pain management/interdisciplinary pain rehabilitation; and

(6) required treatment plans.

(r) The requestor and insurance carrier may voluntarily discuss health care that does not require preauthorization or concurrent utilization review under subsections (p) and (q) of this section respectively.

(1) Denial of a request for voluntary certification is not subject to dispute resolution for prospective review of medical necessity.

(2) The insurance carrier may certify health care requested. The carrier and requestor shall document the agreement. Health care provided as a result of the agreement is not subject to retrospective utilization review of medical necessity.

(3) If there is no agreement between the insurance carrier and requestor, health care provided is subject to retrospective utilization review of medical necessity.

(s) An increase or decrease in review and preauthorization controls may be applied to individual doctors or individual workers' compensation claims by the division in accordance with Labor Code §408.0231(b)(4) and other sections of this title.

(t) The insurance carrier shall maintain accurate records to reflect information regarding requests for preauthorization, or concurrent utilization review approval or adverse determination decisions, and appeals, including requests for reconsideration and requests for medical dispute resolution, if any. The insurance carrier shall also maintain accurate records to reflect information regarding requests for voluntary certification approval/denial decisions. Upon request of the division, the insurance carrier shall submit such information in the form and manner prescribed by the division.

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(u) For the purposes of this section, all utilization review must be performed by an insurance carrier that is registered with, or a utilization review agent that is certified by, the Texas Department of Insurance to perform utilization review in accordance with Insurance Code, Chapter 4201 and Chapter 19 of this title (relating to Agents' Licensing). Additionally, all utilization review agents or registered insurance carriers who perform utilization review under this section must comply with Labor Code §504.055 and any other provisions of Chapter 19, Subchapter U of this title (relating to Utilization Reviews for Health Care Provided under Workers' Compensation Insurance Coverage) that relate to the expedited provision of medical benefits to first responders employed by political subdivisions who sustain a serious bodily injury in course and scope of employment.

The provisions of this §134.600 adopted to be effective December 23, 1991, 16 TexReg 7099; amended to be effective April 1, 1997, 22 TexReg 1317; amended to be effective January 1, 2002, 26 TexReg 9874; amended tobe effective January 1, 2003, 27 TexReg 12359; amended to be effective March 14, 2004, 29 TexReg 2349;amended to be effective May 2, 2006, 31 TexReg 3566; amended to be effective July 1, 2012, 37 TexReg 2420;amended to be effective March 30, 2014, 39 TexReg 2102.

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2 EXHIBIT B CERTIFICATION OF RESTRICTIONS ON LOBBYING

The undersigned certifies, to the best of his or her knowledge and belief, that:

A. No federal appropriated funds have been or will be paid, by or on behalf of the undersigned, to any person for influencing or attempting to influence an office or employee of any agency, a member of Congress, an officer or employee of Congress in connection with the awarding of any federal contract, the making of any federal grant, the making of any federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any federal contract, grant, loan, or cooperative agreement.

B. If any funds other than federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a member of Congress, an officer or employee of Congress, or an employee of a member of Congress in connection with this federal contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard Form-LLL, ‘Disclosure Form to Report Lobbying,’ in accordance with its instructions. After a Contract is awarded by METRO, if applicable, the undersigned is also required to submit to METRO’s Contracting Officer a signed copy of the Form-LLL, ‘Disclosure Form to Report Lobbying,’ for all sub-awards at all tiers in excess of $100,000.00.

C. The undersigned shall require that the language of this certification be included in the award documents for all sub-awards at all tiers (including subcontracts, sub-grants, and contracts under grants, loans, and cooperative agreements) and that all sub-recipients shall certify and disclose accordingly. Once a Contract is awarded by METRO, the undersigned is also required to submit to METRO’s Contracting Officer a signed copy of the certificate for all sub-contracts at all tiers in excess of $100,000.00.

This certification is a material representation of fact upon which reliance is placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by Section 1352, title 31 U.S. Code. Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure.

Executed this _______________ day of ____________________, 20___

Company Name: _____________________________________________

By: ________________________________________________________(Signature of Company Official)

___________________________________________________________(Title of Company Official)

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3 EXHIBIT D DEBARMENT AND SUSPENSION FORM

The undersigned certifies, by submission of this certification, that neither the bidder’s/contractor’s company nor its principals are presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in this transaction by any federal department or agency.

If the company is unable to certify to any of the statements in this certification, the company shall attach an explanation to this

certification.

I hereby certify that I am authorized to execute this certification on behalf of the company and certify the truthfulness and accuracy of the contents herein or attached hereto to the best of my belief. The company does/does not (strike one) have in-house legal counsel.

Company Name: ____________________________________________

By: __________________________________________________Signature of Company Official Date

___________________________________________________Title of Company Official

The following shall also be completed if the Company has in-house legal counsel:

The undersigned legal counsel for ____________________________________ hereby certifies that ____________________________________ has authority under state and local law to comply with the subject assurances and that the certification above has been legally made.

__________________________________________________Signature of Company's Attorney Date

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4 EXHIBIT D SMALL BUSINESS FORMS

Form 1 CONTRACTOR UTILIZATION PLAN FORM

INSTRUCTIONS TO COMPLETING CONTRACTOR UTILIZATION PLAN FORM

The Contractor Utilization Plan outlines the proposer’s/bidder’s team. All team members must be listed on the form regardless of certification status. Make additional copies of the form if needed to include all team members.

Information to be provided:o Name, contact information and tax identification number of prime, subcontractors and supplierso Description of work to be performed by prime, subcontractors, and products to be provided by the supplierso Certification status of prime, subcontractor and suppliers. o Percentage of the contract the prime and each subcontractor and supplier will perform. Total should equal 100%o Price is only included for Invitations for Bid and on the final team plans for Requests for Qualifications or Proposals.

Section 1 – Prime Contractor – this Section is for the proposer’s/bidder’s information. o Contact and tax identification informationo Type of work the prime will performo The certification status of the primeo Percentage of the contract the prime will performo The dollar values of the contract for work performed by the prime (see Information note regarding price information)

Section 2 – Subcontractors – this Section is for all subcontractors’ information regardless of SBE/DBE certification status.o Contact and tax identification informationo Type of work the subcontractor will performo The certification status of the subcontractor. Proof of Certifications must be attached to the form. Confirm acceptable

certification in solicitation documents or on METRO website www.ridemetro.org/ - Small Businesso Percentage of the contract the subcontractor will performo The dollar values of the contract for work performed by the subcontractor (see Information note regarding price information)

Section 3 – Suppliers – Manufacturers – this Section is for all supply manufacturer information.o Contact and tax identification informationo Type of product the manufacturer will provideo The certification status of the manufacturer. Proof of Certifications must be attached to the form. Confirm acceptable

certification in solicitation documents or on METRO website www.ridemetro.org/ - Small Businesso Percentage of the contract the manufacturer will provide – products provided by the manufacturer are counted at 100%o The dollar values of the contract for work performed by the manufacturer (see Information note regarding price information)

Section 4 – Suppliers – Dealers – this Section is for all supply dealer information.o Contact and tax identification informationo Type of product the dealer will provideo The certification status of the dealer. Proof of Certifications must be attached to the form. Confirm acceptable

certification in solicitation documents or on METRO website www.ridemetro.org - Small Businesso Percentage of the contract the dealer will provide – products provided by the dealer are counted at 60%

List percentage of effort at 100% List percentage of effort at 60% - this is the amount that will be counted towards the Small Business Goal if provided by a

METRO-certified Small Business or TUCP-certified Disadvantaged Business dealero The dollar values of the contract for work performed by the Dealer (see Information note regarding price information)

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RFQ No. 4019000014

Bidder/Proposer presents the following participants in this solicitation and any resulting contract.

Section 1 – PRIME CONTRACTOR Type of Work to be Performed or Materials Supplied

Indicate if SBE/DBE

Y/NPercent of

contract EffortPrice

(IFB ONLY)SBE DBE

Name of Business

Tax ID No.

Business Address

Telephone No.

Fax No.

Contact Person

Email Address

____________________________________

____________________________________

____________________________________

____________________________________ ____________________________________

____________________________________

____________________________________

Section 2 – SUBCONTRACTORS Type of Work to be Performed or Materials Supplied

Indicate if SBE/DBE

Y/NPercent of

contract EffortPrice

(IFB ONLY)SBE DBE

Name of Business

Tax ID No.

Business Address

Telephone No.

Fax No.

Contact Person

Email Address

____________________________________

____________________________________

____________________________________

____________________________________ ____________________________________

____________________________________

____________________________________

Name of Business

Tax ID No.

Business Address

Telephone No.

Fax No.

Contact Person

Email Address

____________________________________

____________________________________

____________________________________

____________________________________ ____________________________________

____________________________________

____________________________________

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RFQ No. 4019000014

Bidder/Proposer presents the following participants in this solicitation and any resulting contract.

Section 3 –SUPPLIERS – MANUFACTURERS100%

Counts for 100% toward small business goal when purchased from small business manufacturer (see Instructions to Bidders/Proposers).

Type of Work to be Performed or Materials SuppliedIndicate if SBE/DBE

Y/NPercent of

contract Effort (100%)

Price(IFB ONLY)

SBE DBEName of Business

Tax ID No.

Business Address

Telephone No.

Fax No.

Contact Person

Email Address

____________________________________

____________________________________

____________________________________ ____________________________________

____________________________________

____________________________________

Name of Business

Tax ID No.

Business Address

Telephone No.

Fax No.

Contact Person

Email Address

____________________________________

____________________________________

____________________________________ ____________________________________

____________________________________

____________________________________

Name of Business

Tax ID No.

Business Address

Telephone No.

Fax No.

Contact Person

Email Address

____________________________________

____________________________________

____________________________________ ____________________________________

____________________________________

____________________________________

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RFQ No. 4019000014

Bidder/Proposer presents the following participants in this solicitation and any resulting contract.

Section 4 –SUPPLIERS – DEALERS60%

Counts for 60% toward small business goal when purchased from small business regular dealer (see Instructions to Bidders/Proposers).

Type of Work to be Performed or Materials Supplied

Indicate if SBE/DBE

Y/NPercent of

contract Effort Price(IFB ONLY)

SBE DBE% of Effort At 60%

Name of Business

Tax ID No.

Business Address

Telephone No.

Fax No.

Contact Person

Email Address

____________________________________

____________________________________

____________________________________

____________________________________ ____________________________________

____________________________________

____________________________________

Name of Business

Tax ID No.

Business Address

Telephone No.

Fax No.

Contact Person

Email Address

____________________________________

____________________________________

____________________________________

____________________________________

____________________________________

____________________________________

____________________________________

TOTAL AMOUNT OF BID/PROPOSAL SBE/DBE Participation

PRIME: $_________________ ______%SUBCONTRACTOR(S): $_________________ ______%

SUPPLIER(S) MANUFACTURERS:$_________________ ______%SUPPLIERS(S) DEALERS:$_________________ ______%

TOTAL BID/PROPOSAL AMOUNT: $_________________ ______%

The Contractor agrees to adhere to this Plan submitted unless a waiver is received from the Office of Small Business. Any changes in the Plan regarding the proposed use of certified subcontractors in discharging the contract duties must be approved by the Office of Small Business. The approval of the Office of Small Business will not be unreasonably withheld upon a showing of good cause to make the change.

Submitted By: _____________________________________________ Business Name: ______________________________________Signature of Owner/Officer of Business (Date)

Address: _________________________________________________ Telephone/Email: _____________________________________

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RFQ No. RFQ No. 4019000014

Form 2 BUSINESS ASSURANCE STATEMENT

The undersigned certifies that he/she has read, understands and agrees to be bound by the small business provisions set forth in this Solicitation. The undersigned further certifies that he/she is legally authorized by the bidder/contractor to make the statements and representations in this solicitation and that said statements and representations are true and accurate to the best of his/her knowledge and belief. The undersigned agrees to attain the small business utilization percentages of the total offer amount as set forth below:

Small Business contract Goal Commitment = __% - must match commitment on the Contractor Utilization Plan form

The undersigned will enter into formal agreement(s) for work to be identified on the ‘Contractor Utilization Plan Form’ form conditioned upon execution of a contract with METRO and agrees to include the two assurance statements below in all subcontracts.

Copies of the subcontract agreements will be submitted to the Contracting Officer within fifteen 15 days of contract award and within fifteen 15 days of the addition of new subcontractors to the Contractor Utilization Plan.

The undersigned certifies that the firm shown below has not discriminated against any subcontractors because of race, color, religion, sex, age, disability or ethnic or national origin, but has provided full and equal opportunity to all potential subcontractors irrespective of race, color, religion, sex, age, disability, or ethnic or national origin.

The undersigned understands that if any of the statements and representations are made knowing them to be false or there is a failure to implement any of the stated intentions, objectives, goals, and commitments set forth herein without prior approval of METRO's President & Chief Executive Officer or duly authorized representative, the bidder/contractor will be subject to the loss of any Contractor, the termination thereof resulting from this bid, and could be ineligible for future METRO contract awards.

Signature: ___________________________________________

Title: _______________________________________________ Date of Signing: ________________

Firm or Corporation: ______________________________________________________________________

Address: _______________________________________________________________________________

______________________________________________________________________________________

Telephone Number: __________________________________

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RFQ No. RFQ No. 4019000014

Form 3 SUBCONTRACTOR/SUPPLIER LETTER OF INTENT

PLEASE SUBMIT SEPARATE FORMS FOR EACH SUBCONTRACTOR/SUPPLIER

For use by submitters to identify subcontractors and suppliers.

Solicitation No.: _________________________

Project Title: _________________________________________________________________________________________________

Prime Contractor: _____________________________________________________________________________________________

Subcontractor/Supplier: ______________________________________________________________________________________

Small Business Yes No Disadvantaged Business: Yes No

Contact Name: _______________________________________________________________________________________________

Address: ____________________________________________________________________________________________________

Phone: ______________________________________ Fax: _____________________________________________________

Period of Performance: ________________________________________________________________________________________

Description of proposed materials or services to be performed under the Contract Utilization Plan:

____________________________________________________ ________________________________________________Signature of Subcontractor/Supplier Title

_____________________________________________________ ________________________________________________Signature of Prime Contractor Title

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RFQ No. RFQ No. 4019000014

Form 4 CONTRACTOR UTILIZATION PLAN PLEDGE

Copies of the Subcontract Agreements will be submitted to the Contracting Officer within fifteen (15) days of Contract award and within fifteen (15) days of the addition of new Subcontractors to the Contractor Utilization Plan and will include the Clauses below:

Pledge of Prompt Payments

I pledge to pay all Subcontractors within five (5) business days after receiving payment from METRO for amounts previously invoiced for work performed or materials furnished under the Contract.

Signature: _________________________________

Title: _____________________________________

Date: ____________________________________

METRO’s Nondiscrimination Mandate

I affirm that ___________________________ (Company name) adheres to METRO’s Nondiscrimination Mandate and has not discriminated against any subcontractors in considering subcontracting opportunities based on race, sex, religion or ethnic origin, age or disability.

Signature: _________________________________

Title: _____________________________________ Date: _____________________________________

(FOR CONSTRUCTION CONTRACTS)

I pledge to release the retainage of all Subcontractors within thirty (30) days after satisfactory completion and approval of work performed. Subcontractors may petition the prime Contractor to make the final payment and may notify METRO of the request. As METRO releases retainage for payment to the Subcontractor, the prime Contractor is required to immediately (within 15 days) pay the Subcontractor. The release of retainage will be made to the Subcontractor regardless of the prime invoicing METRO.

Signature: _________________________________

Title: _____________________________________

Date: _____________________________________

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RFQ No. RFQ No. 4019000014

5 EXHIBIT E CODE OF ETHICS OF THE METROPOLITAN TRANSIT AUTHORITY

Please refer to the current versions of METRO’s Codes of Ethics for METRO Employees and for the METRO Board of Directors at https://www.ridemetro.org/Pages/ConflictsDisclosure.aspx

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