Modification to a Previous Presolicitation Notice – Sources Sought Notice for Medicare Administrative Contractor (MAC) Services, Medicare Parts A & B, Jurisdictions F, 8 and H
Modification to a Previous Presolicitation Notice - Sources Sought Notice for Medicare Administrative Contractor (MAC) Services, Medicare Parts A & B, Jurisdictions F, 8 and H
Notice Type: Modification to a Previous Presolicitation Notice
Posted Date:
Office Address:
Subject: Sources Sought Notice for Medicare Administrative Contractor (MAC) Services, Medicare Parts A & B, Jurisdictions F, 8 and H
Classification Code: R - Professional, administrative, and management support services
Solicitation Number:
Contact:
Description:
********UPDATED TO REFLECT CHANGE IN RESPONSE DUE DATE FROM
Medicare Parts A and B (Medicare Fee for Service), Jurisdiction F, 8, H
Introduction
This SOURCES SOUGHT NOTICE is to determine the availability and capability of potential small businesses (e.g., 8(a), service-disabled veteran owned small business, HUBZone small business, small disadvantaged business, veteran-owned small business, and women-owned small business) that can provide specific fee-for-service (FFS) health insurance benefit administration services, including
The information attained through this market research will assist the
Please note the CMS will rely on the results of this market research when conducting acquisitions for MAC services in multiple geographical jurisdictions over multiple years, including those listed above (Jurisdiction F, 8, and H).
THIS IS STRICTLY MARKET RESEARCH. CMS WILL NOT ENTERTAIN QUESTIONS REGARDING THIS MARKET RESEARCH.
Background and Purpose of Acquisition
Prior to 2015, Section 1874A under Title XVIII of the Social Security Act required CMS to re-compete its Medicare Fee-for-Service (FFS) benefit and claims administration (MAC) contracts at least once every five years. As of
The purpose of the acquisition is to procure an A/B MAC to perform numerous Medicare Program functions to support healthcare payments on behalf of
- Part A/B Jurisdiction 8 includes:
- Part A/B Jurisdiction H includes:
Response Information
Responses to this notice, shall demonstrate capability to perform the following, assuming the workload volumes and performance standards stated below: Responses based upon anticipated teaming arrangements and Joint Ventures are acceptable. The capability of each team member (prime contractor and sub-contractors) shall be demonstrated relative to the anticipated functions/roles to be performed by each. Potential small businesses shall also include the business information outlined in the section below as part of their response.
In accordance with CMS's technical specifications, potential offerors must demonstrate its capability to receive, control, and pay
Potential offerors must demonstrate capability 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. An edit is logic within the Standard Claims Processing System, or
3. In accordance with CMS's technical specifications, potential offerors must demonstrate capability to enroll
4. Potential offerors must demonstrate capability to calculate
5. Potential offerors must also demonstrate capability to conduct a variety of
6. Potential offerors must demonstrate capability to operate
7. Potential offerors must demonstrate capability to conduct redeterminations on appeals of claims, respond to complex beneficiary inquiries referred from the Beneficiary contact Centers, conduct Medical Review on selected claims, and conduct rigorous quality control on the millions of claims processed each year.
8. Potential offerors must demonstrate capability to utilize or interact with certain CMS-required payment schedules, systems, equipment and/or operational capabilities in the performance of its functions.
9. Potential offerors must demonstrate capability to coordinate activities with CMS, and 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
10. Potential offerors must demonstrate capability of reviewing, accounting for, and adapting to and implementing up to five hundred Change Requests (CR) issued by CMS each year. This includes the ability to track the impact of the CRs on contract performance, from both cost and technical perspectives.
11. Potential offerors must demonstrate capability to obtain and/or maintain an Authority to Operate from CMS, and have policies, procedures and practices for fulfilling the
Jurisdiction Volumes
The volume information provided below is for mission essential operational areas and not intended to represent every operational area of an A/B MAC contract. We have also included performance requirement level information for the specific operational area noted, for ease of reference. The full set of requirements and Performance Measures are provided in the attached documents. For each full year of the A/B MAC JF contract, the MAC is required to perform the following program requirements in the states noted:
Jurisdiction F:
* Process approximately 14 million Part A (institutional provider) and 58 million Part B (practitioner and supplier) claims.
* Process approximately 123,000
PERFORMANCE REQUIREMENTS:
- Claims processing is successful when claims are paid with acceptable accuracy as evidenced by a contractor-specific Comprehensive Error Rate Testing (CERT) error rate not to exceed the Government Performance Results Act (GPRA) national paid claims error rate goal for the year (The goal for each year is published in the Report on Improper Medicare Fee-for-Service Payments. http://www.cms.hhs.gov/cert [www.cms.hhs.gov/cert]).
- Clean claims are processed timely when 95% of the Part A and Part B of A claims processed in the Fiscal Intermediary Standard System (FISS) are processed within the claims payment floor and ceiling specified in the
- Clean claims are processed timely when 95% of the Part B claims processed in the Medical Claims System (MCS) are processed within the claims payment floor and ceiling specified in
- Other-Than-Clean claims are processed timely when 100% of the claims are processed within 45 days of the receipt (
- Reopening: Where appropriate, the Contractor shall reopen an initial determination or a redetermination to review a decision in accordance with 42 Code of Federal Regulations (CFR) 405.980 and Internet Only Manual (IOM) 100-4, Chapter 34.
- Reopening Decisions: The Contractor shall issue its revised determination or decision to the parties to the initial determination or redetermination in accordance with 42 CFR 405.982.
- Redetermination Requests: The Contractor shall process requests for redetermination of
- Conduct and Notice of the Redetermination: Contractors shall prepare notice of the redetermination in accordance with 42 CFR 405.956 and IOM 100-4, Chapter 29, section 310. Contractors shall process and mail all redeterminations within 60 calendar days of the date the Contractor receives a timely filed request for redetermination.
- Appeal Decision Effectuation: The Contractor shall take all necessary payment actions on all levels of appeal (redeterminations, reconsiderations, ALJ decisions,
* Timely, accurately, and effectively respond to more than1.7 million inquiries (telephone, written, electronic) from
PERFORMANCE REQUIREMENTS:
- Electronic Correspondence Referral System Status Inquiries: Status inquiries are performed in accordance with
- Medicare Secondary Payer (MSP) Claims Inquiries: The Contractor shall respond to inquiries and correspondence from insurers and other interested parties (e.g., attorneys and/or beneficiaries, etc.) on MSP billing requirements to assist with resolving claims inquiries accurately, timely, and responsively in accordance with
- Inquiries Specific to Debt Collection Efforts for Providers, Physicians and other Suppliers: Inquiries specific to debt collection efforts are successful when 95% of all provider, physician and other supplier MSP inquiries shall be acknowledged or responded to within 45 days of receipt, absent IOM instructions to the contrary.
- Responses to Congressional Inquiries: Congressional written inquiries are timely when 100% are answered within 10 business days, including any that may be received from a CMS RO. For those Congressional inquiries that cannot be answered in final within 10 business days, the Contractor shall issue an interim response within 10 business days explaining the reason for the delay. Any interim responses sent to Congressional inquiries shall count toward the Contractor's overall allowance of no more than 5% of interim responses for the universe of written inquiries.
- Telephone Inquiries - Quality: Of all telephone calls monitored for the quarter, the percentage of calls scoring as "Achieves Expectations" or higher for Knowledge Skills and Customer Skills and scoring as "Pass" for Adherence to Privacy Act using the Quality Call Monitoring tool shall be no less than 93% (cumulative for the quarter).
- Telephone Inquiries -- Call Completion Rate: The provider contact center shall complete at least 95% of incoming calls on an Interactive Voice Response (IVR)-only line, 80% of incoming calls on a CSR-only line, and 80% of incoming calls on an IVR/CSR combined line as measured on a quarterly basis.
- Telephone Inquiries -- Average Speed of Answer: The provider contact center shall maintain an average speed of answer of 60 seconds or less when measured on a quarterly basis.
- Written Inquiry Responses -- Timeliness: All (100%) written provider general inquiries shall be responded to within 45 business days of receipt with either a final response or an interim response; and no more than 5% of the universe of written responses to provider inquiries shall be interim responses.
* Timely and accurately process more than 116,000 provider enrollment actions (various types of providers and enrollment actions).
PERFORMANCE REQUIREMENTS:
- Process Initial and Revalidation Enrollment Applications (Paper): The contractor shall process all initial and revalidation CMS-855 Applications in accordance with all of the instructions found in the timeliness standards in Pub. 100-08, Chapter 15.
- Process Initial and Revalidation Enrollment Applications (Paper): The applications described in C.5.5.1 of this SOW will be considered accurately processed when 98%of applications are processed in accordance with all of the instructions in
- Process Initial and Revalidation Enrollment Applications (Web-based): The Contractor shall process all initial web-based enrollment applications in accordance with all of the instructions found in the timeliness standards in Pub. 100-08, Chapter 15.
- Process Changes, Updates, Reassignments or Corrections: Paper applications described in C.5.5.2 of this SOW shall be processed in accordance with all the instructions found in the timeliness standards in Pub. 100-08, Chapter 15.
- Process Changes, Updates, Reassignments or Corrections: Web-based applications described in C.5.5.2 of this SOW shall be processed in accordance with all of the instructions found in the timeliness standards in Pub. 100-08, Chapter 15.
- Process Changes, Updates, Reassignments or Corrections: The applications described in C.5.5.2 of this SOW will be considered accurately processed when 98% of applications are processed in accordance with all of the instructions in
- Revocations/Deactivations: The Contractor shall process 100% of all revocation actions in accordance with the revocation instructions in
- Revocations/ Deactivations: The Contractor shall deactivate
- Provider Enrollment Appeals: The Contractor shall process 100% of all provider enrollment appeals in full accordance with all appeals instructions in
-
* Timely and accurately receive, analyze, desk review and settle (or tentatively settle) several thousand provider cost reports.
PERFORMANCE REQUIREMENTS:
- Cost Report Acceptance: Cost report acceptance is timely if it is completed within 30 days from the receipt date of the provider's cost report.
- Cost Report Acceptance: Cost report reminder letters are timely when a CMS review indicates that they are performed in accordance with
- Cost Report Acceptance: Suspension/reduction of a provider's payments due to untimely filing of a cost report is accurate when a CMS review indicates they are performed in accordance with
- Cost Report Acceptance: Suspension/reduction of a provider's payments due to a rejected cost report is accurate when a CMS review indicates they are performed in accordance with
- Tentative Settlements: Tentative settlements are timely when they are completed within 60 days of the acceptance of the provider's cost report.
- Tentative Settlements: Tentative settlements are accurate when a CMS review indicates that they are performed in accordance with
- Tentative Settlements: Cost to Charge Ratios are calculated accurately when a CMS review indicates that they are in compliance with
- Desk Reviews / Provider Permanent Files: A provider's permanent file is considered properly maintained when a CMS review indicates that it is maintained in accordance with
- Audits of Home Office Cost Statements: Audited home office cost statements are properly distributed to servicing contractors if the designated home office contractor accurately distributes the audited home office cost statement and audit adjustments to all servicing contractors at the completion of the audit in accordance with
- Final Settlement: Cost reports that do not require an audit are settled timely when the
- Final Settlement: Cost reports are settled accurately when CMS review determines compliance with
- Final Settlement: Cost reports that are audited shall have an
- Final Settlement: Outlier reconciliations are considered accurate when a CMS review indicates that they are in compliance with
- Cost Report Reopenings: Revised NPRs are timely when they are issued within 180 days of receipt of all information and documentation necessary to resolve the reopening issue.
- Cost Report Reopenings: Revised NPRs are accurate when a CMS review determines compliance with
- Cost Report Reopenings: Notices or denials of cost report reopenings are accurate when a CMS review determines compliance with
- Cost Report Reopenings: Cost report reopenings are accurate when CMS review determines compliance with
- Appeals:
- Exception Requests: Tax Equity and Fiscal Responsibility Act (TEFRA): Target Limits are timely when applications are processed to completion within 75 days after receipt by the Contractor or returned to the hospital as incomplete within 60 days of receipt.
- Exception Requests: Tax Equity and Fiscal Responsibility Act: Target Limits are accurate when they comply with TEFRA payment policy.
- System for Tracking Audit and Reimbursement System (STAR): STAR database is maintained accurately and timely when a CMS review indicates that it is in compliance with the STAR manual.
* Timely and accurately conduct more than 61,000 clinical medical records reviews to determine medical necessity for
PERFORMANCE REQUIREMENT:
- Medical Review: Medical Review is successful when claims are paid with acceptable accuracy as evidenced by a contractor-specific Comprehensive Error Rate Testing (CERT) error rate not to exceed the Government Performance Results Act (GPRA) national paid claims error rate goal for the year (The goal for each year is published in the Report on Improper Medicare Fee-for-Service Payments. www.cms.hhs.gov/cert).
-
For each full year of the JH and J8 A/B MAC contracts, the MAC is required to perform the same SOW program requirements at the level of the stated Performance Requirements. The volumes specific to J8 and JH are provided below:
Jurisdiction 8:
* Process approximately 13 million Part A (institutional provider) and 56 million Part B (practitioner and supplier) claims.
* Process approximately 81,000
* Timely, accurately, and effectively respond to more than one million inquiries (telephone, written, electronic) from
* Timely and accurately process more than 86,000 provider enrollment actions (various types of providers and enrollment actions).
* Timely and accurately receive, analyze, desk review and settle (or tentatively settle) several thousand provider cost reports.
* Timely and accurately conduct more than 62,000 clinical medical records reviews to determine medical necessity for
Jurisdiction H:
* Process approximately 25 million Part A (institutional provider) and 131 million Part B (practitioner and supplier) claims.
* Process approximately 3 million
* Timely, accurately, and effectively respond to more than two million inquiries (telephone, written, electronic) from
* Timely and accurately process more than 198,000 provider enrollment actions (various types of providers and enrollment actions).
* Timely and accurately receive, analyze, desk review and settle (or tentatively settle) several thousand provider cost reports.
* Timely and accurately conduct more than 166,000 clinical medical records reviews to determine medical necessity for
Systems Access and Security Considerations
A/B MAC contractors access/use numerous CMS Medicare FFS systems to perform
* The Federal Intermediary Standard System (FISS) system for processing
* The Medical Claims System (MCS) for processing
* The Common Working File system, for additional processing and authorization of all claim types.
* The Common Edit Module (CEM), which the A/B MAC will integrate into its electronic claims receipt capability.
* The Provider Enrollment Chain and Ownership System (
* The Healthcare Integrated General Ledger Accounting System (HIGLAS) to post and maintain
* The System for Tracking Audit and Reimbursement (STAR) system, to manage and control
* The Medicare Appeals System (MAS), to manage and control its claims appeals workload.
* The Integrated Data Repository, to support the A/B MAC's data analytics responsibilities.
* The Contractor Reporting of Operational and Workload Data (CROWD) system, for reporting of A/B MAC claims and other workload data, and other CMS reporting systems.
CMS may create additional IT systems in the future to support the ongoing development of the Medicare FFS program, and the A/B MAC contractor may be required to develop processes and/or interfaces with such additional CMS systems to perform its duties (historically, these scenarios are one of many causes for SOW revisions post-award).
In addition to serving as a user of numerous CMS systems, the A/B MAC contractor will itself provide additional IT systems and capabilities, particularly systems and capabilities to support its
Due to their enormous responsibilities as custodians of
Business Information
1. DUNS:
2. Company
3. Company Address
4. Do you have a Government approved accounting system If so, please identify the agency that approved the system.
5. Type of Company (i.e., small business, 8(a), woman owned, veteran owned, etc.) as validated via the System for Award Management (SAM) via www.sam.gov. Registration via www. SAM.gov is a requirement for qualifying as a prime contractor with the CMS. Furthermore, the small business size standard for the north American Industry Classification System (NAICS) listed above will be applicable.
6.
Teaming Arrangements
All teaming arrangements should also include the above-cited information and certifications for each entity on the proposed team. Teaming arrangements are encouraged.
Response Due Date
Responses must be submitted electronically not later than
contact information
Contracting Officer:
Contract Specialist:
Link/URL: https://www.fbo.gov/spg/HHS/HCFA/AGG/SSN-AB-MACs(JF-J8-JH)/listing.html
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