Description: Department of Health and Human Services
Centers for Medicare & Medicaid Services
Office of Acquisition and Grants Management
The purpose of this contract is to obtain a Medicare Administrative Contractor (hereinafter referred to as "the contractor" or "MAC") to provide specified health insurance benefit administration services, including Medicare claims processing and payment services, in support of the Medicare program (also known as the Medicare fee-for-service, or FFS, program) for Jurisdiction J. Jurisdiction J includes the following states: Alabama, Georgia and Tennessee. The Contractor shall perform its responsibilities under the direction of CMS. The Contractor shall perform numerous functions to support health care services for Medicare beneficiaries, which include performing claims-related activities and establishing relationships with providers of Medicare services, both institutional and professional, both in-patient (Part A) and out-patient (Part B) for a defined geographic area or "jurisdiction." The Contractor will perform the requirements of this contract in accordance with applicable laws, regulations, Medicare manuals, as well as CMS requirements to ensure the financial integrity of the Medicare FFS program.
The Medicare FFS program has complex legal, policy, and operating environments. The Contractor shall be familiar with, utilize and interact with all pertinent CMS-required payment schedules, systems, equipment, and operational capabilities in the performance of its functions. Further, the Contractor will coordinate its activities not only with CMS, but must also work with a broad range of Federal, State, and Local government agencies, CMS partners and Contractors, and a diverse range of stakeholders in the health care system of the United States. In accordance with CMS' technical specifications, the Contractor shall receive and control Medicare claims from institutional and professional providers, suppliers, and beneficiaries within its jurisdiction, and will perform all standard or otherwise required editing with respect to these claims to determine whether they are complete and should be paid. An edit is the logic within the Standard Claims Processing System (or PSC/ZPIC 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 operates a provider customer service program and conducts a variety of Medicare provider and supplier outreach and response services, such as education regarding Medicare rules and regulations, billing procedures and answering telephone and written inquiries. The Contractor will also operate Medicare's provider and supplier toll-free lines across the country to respond to a wide-range of questions.
Further, the Contractor conducts redeterminations on appeals of claims, responds to complex beneficiary inquiries referred to from the Beneficiary contact Centers, performs Medical Review on selected claims, makes coverage decisions for new procedures and devices in local area, 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 Contractors processes and systems, and implements these changes in the timeframes specified in the Change Requests.
CMS anticipates releasing a solicitation for Jurisdiction J on or about April 14, 2016. The contract will include a base year plus four one-year options. The anticipated proposal due date is June 13, 2016 with an anticipated award date of October 31, 2016.
This solicitation is expected to be issued as pending availability of funds.