Sources Sought Notice – FEE-FOR-SERVICE MEDICARE ADMINISTRATIVE CONTRACTOR -Medicare Parts A and B – Jurisdiction F, H, and 8

Notice Type: Sources Sought Notice

Posted Date: 14-APR-15

Office Address: Department of Health and Human Services; Centers for Medicare & Medicaid Services; Office of Acquisition and Grants Management; 7500 Security Blvd.C2-21-15 Baltimore MD 21244-1850

Subject: FEE-FOR-SERVICE MEDICARE ADMINISTRATIVE CONTRACTOR -Medicare Parts A and B - Jurisdiction F, H, and 8

Classification Code: G - Social services

Solicitation Number: CMS-MAC160013

Contact: Craig M.Dash, Phone 4107861221, Email Craig.Dash@cms.hhs.gov - Kristen C. Krammer, Phone 4107864630, Email Kristen.lawrence@cms.hhs.gov

Setaside: N/AN/A

Place of Performance Country: US

Description: Department of Health and Human Services

Centers for Medicare & Medicaid Services

Office of Acquisition and Grants Management

FEE-FOR-SERVICE MEDICARE ADMINISTRATIVE CONTRACTOR MEDICARE PARTS A AND B JURISDICTION F, H AND 8 SOURCES SOUGHT NOTICE 4.14.15 Introduction This SOURCES SOUGHT NOTICE is to determine the availability of potential small businesses (as listed in the next paragraph at (2)) that can provide specific fee-for-service (FFS) health insurance benefit administration services, including Medicare claims processing and payment services, in support of the "traditional" Medicare program (also known as the Medicare fee-for service, or FFS program) in accordance with the Draft Statement of Work (SOW) entitled A/B Medicare Administrative Contractor (MAC) SOW (attached).

This is a Small Business Sources Sought notice. This is NOT a solicitation for proposals, proposal abstracts, or quotations. The purpose of this notice is to obtain information regarding: (1) the availability and capability of qualified small business sources; (2) whether they are small businesses; HUBZone small businesses; service-disabled, veteran-owned small businesses; 8(a) small businesses; veteran-owned small businesses; woman-owned small businesses; or small disadvantaged businesses; and (3) their size classification relative to the North American Industry Classification System (NAICS) code for the proposed acquisition. Your responses to the information requested will assist the Government in determining the appropriate acquisition method, including whether a set-aside is possible. An organization that is not considered a small business under the applicable NAICS code should not submit a response to this notice.

The information from this market research will help the Centers for Medicare & Medicaid Services (CMS) plan their acquisition strategy. THIS IS STRICTLY MARKET RESEARCH. CMS WILL NOT ENTERTAIN QUESTIONS REGARDING THIS MARKET RESEARCH. Background As required by section 911 of the Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA), CMS must re-compete its MAC contracts every five (5) years. The purpose of this contract is to obtain a MAC (hereinafter, referred to as "the Contractor") to provide specified health insurance benefit administration services, including Medicare claims processing and payment services, in support of the Medicare FFS program. The Contractor shall perform its responsibilities under the direction of CMS.

The Contractor shall perform numerous functions on behalf of Medicare beneficiaries and shall establish relationships with providers of Medicare services, both in-patient (Part A) and out-patient (Part B) for a defined geographic area or "jurisdiction." The Contractor shall perform the requirements of this contract in accordance with applicable laws, regulations, Medicare manuals and CMS requirements to ensure the financial integrity of the Medicare FFS program.

The Medicare FFS program's legal, policy and operating environment is complex, and the Contractor shall be familiar with and utilize or interact with certain CMS-required payment schedules, systems, equipment and/or operational capabilities in the performance of its functions. Further, the Contractor shall coordinate its activities not only with CMS, but also with a broad range of agencies at the federal, state and local levels of government, other CMS partners and Contractors, and a diverse range of stakeholders within the health care system of the United States.

In accordance with CMS' technical specifications, the Contractor shall receive and control Medicare claims from providers, suppliers and beneficiaries within its jurisdiction, as well as perform edits on these claims to determine whether the claims are complete and should be paid. An edit is logic within the Standard Claims Processing System, or Program Integrity Supplemental Edit Software, that selects certain claims, evaluates or compares information on the selected claims or other accessible source, and, depending on the evaluation, takes action on the claims, such as pay in full, pay in part, or suspend for manual review. Contractors must be able to determine the need for locality-driven edits in their jurisdiction, as well as those included in the Standard and Supplemental systems, and to develop the logic for those local coverage determinations.

In addition, the Contractor calculates Medicare payment amounts and remits these payments to the appropriate party. The Contractor also conducts a variety of different Medicare provider and supplier outreach and response services, such as education and on Medicare's rules and regulations and billing procedures, and answering written inquiries. The Contractor also operates Medicare's provider and supplier toll-free lines across the country to answer a wide-range of questions.

Additionally, the Contractor conducts redeterminations on appeals of claims, responds to complex beneficiary inquiries referred from the Beneficiary contact Centers, does Medical Review on selected claims, and conducts rigorous quality control on the tens of millions of claims processed each year. The Contractor shall receive and review over five hundred Change Requests issued by CMS each year to modify the systems and services offered by Medicare, determine the impact of the Change Requests on the Contractor's processes and systems, and implement these changes in the timeframes specified in the Change Requests.

This Sources Sought notice is targeted for:

Part A/B Jurisdiction F: Alaska, Arizona, Idaho, Montana, North Dakota, Oregon, South Dakota, Utah, Washington, and Wyoming

Part A/B Jurisdiction H: Arkansas, Colorado, Louisiana, Mississippi, New Mexico, Oklahoma, and Texas Part A/B Jurisdiction 8: Indiana and Michigan Response Information

The following historical information is provided below to further illustrate the type of businesses that have previously conducted the SOW requirements: a. Staffing of between 650-1000 FTEs In order to respond to this notice, potential small businesses are requested to provide the CMS all appropriate documentation (i.e., a detailed and/ or relevant past performance history documenting its ability to perform similar SOW requirements). The contractor under this Part A/B MAC contract shall be capable of operating a large, complex federal program that requires the management and processing of complex data; operating high volume administrative and technical support programs; implementing project management controls; significant multi-tasking; and ability to control costs to support its ability to carry-out the requirements of the SOW. Furthermore, the capability statement and/or relevant past performance history should:

Identify its specific experience/capabilities in:

a. Administrative and technical review of Part A/B Medicare FFS claims. Utilization of certain CMS-required payment schedules, systems, equipment, and operational capabilities in the performance of its functions.

b. Medicare payments of Part A/B Medicare FFS claims - ability to receive and control Medicare claims from institutional and professional providers, suppliers, and beneficiaries within its jurisdiction and perform standard or required editing on these claims to determine whether the claims are complete and should be paid. Calculates Medicare payment amounts and arranges for remittance of these payments to the appropriate party.

c. Customer Service related to Part A/B Medicare FFS claims - ability to operate a Provider Customer Service Program (PCSP) that educates providers about the Medicare program and responds to provider telephone and written inquiries; responds to complex inquiries from Call Center Operations (CCOs).

d. Medical Review of Part A/B Medicare - and experience in making coverage decisions for new procedures and devices in local areas.

e. Provider Enrollment -experience with CMS provider enrollment process ensuring that only qualified providers, practitioners, or other entities are enrolled and maintain their billing privileges in the Medicare program. Business Information Potential small businesses shall also include the business information outlined in the section below as part of their response. 1. DUNS: 2. Company Name 3. Company Address 4. Current GSA Schedules appropriate to this Sources Sought 5. Do you have a Government approved accounting system If so, please identify the agency that approved the system. 6. Type of Company (i.e., small business, 8(a), woman owned, veteran owned, etc.) as validated via the Central Contractor Registration (CCR). All offerors must register on the System for Award Management (SAM) located at https://www.sam.gov/index.html/#1. 7. Company Point of contact, Phone, and Email address

Teaming Arrangements Teaming arrangements are encouraged and should show the collective experience of the proposed team. Please include the above-cited information and certifications for each entity on the proposed team. Response Due Date Responses must be submitted electronically not later than 11:00 AM Eastern Standard Time, Tuesday, May 5, 2015. Submissions should be sent to the Contracting Officer and Contract Specialist, contact information below. Capability statements will not be returned and will not be accepted after the due date. The maximum number of pages for submission is 10 pages.

This Sources Sought Notice is for information and planning purposes only and is not to be construed as a commitment by the Government. This is not a solicitation announcement for proposals and no contract will be awarded from this Notice. No reimbursement will be made for any costs associated with providing information in response to this Notice. Respondents will not be notified of the results of CMS' review of any submission.

contact information Contracting Officer: Craig Dash, e-mail Craig.Dash@cms.hhs.gov ; phone 410-786-1221

Contract Specialist: Kristen Lawrence, e-mail Kristen.Lawrence@cms.hhs.gov ; phone 410.786.4630

Link/URL: https://www.fbo.gov/spg/HHS/HCFA/AGG/CMS-MAC160013/listing.html