Sources Sought Notice – Common Working File (CWF) Maintenance

Notice Type: Sources Sought Notice

Posted Date: 22-FEB-16

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: Common Working File (CWF) Maintenance

Classification Code: D - Information technology services, including telecommunications services

Solicitation Number: 170409

Contact: Andrew J. Anuszewski, Contract Specialist, Phone 4107862003, Email [email protected] - Charles Littleton, Contracting Officer, Phone 410-786-3291, Fax 410-786-9088, Email [email protected]

Description: Department of Health and Human Services

Centers for Medicare & Medicaid Services

Office of Acquisition and Grants Management

Sources Sought Notice Introduction

This is a SOURCES SOUGHT NOTICE posted for INFORMATIONAL PURPOSES ONLY. It will be used to obtain information regarding the availability and capability of small businesses (e.g.: 8(a), service-disabled veteran owned small businesses, HUBZone small businesses, women-owned small businesses and small businesses) to provide the services described herein. The Centers for Medicare & Medicaid Services (CMS) will use the information received to determine if the work described herein will be set-aside for small business. Based upon the results of the evaluation of the respondents' capability, CMS may set the work aside for a specific type of small business (i.e. HubZone, WOSB, SDVOSB, or 8(a)), small business, or determine that the work should be competed on an unrestricted basis.

Background

The Medicare program is a Federal health insurance program. The program benefits senior citizens aged 65 or older and those who are disabled or diagnosed with chronic renal disorders. CMS has the primary responsibility for administering the Medicare program as delegated by the Secretary of the Department of Health and Human Services (DHHS). CMS administers the Medicare program on a day-to-day basis, including formulation and promulgation of Medicare policy and guidance, contract execution, operation and management, maintenance and review of utilization records, and general Medicare financing. CMS is the largest purchaser of health care in the United States.

It is CMS' mission to assure high quality health care for all beneficiaries. This contract specifically applies that mission by fostering excellence in the design and administration of CMS' programs. Within the timeframe of this contract, that mission has the following objectives:

1. Stabilize the Medicare claims processing environment 2. Modernize CMS' systems and databases and reduce system maintenance costs while extending the life of the system 3. Move toward standardizing all SSMs 4. Improve system quality and performance 5. Incorporate legislative and CMS mandates 6. Implement changes and enhancements

It is CMS' goal to achieve these objectives by improving the quality and timeliness of Medicare business requirements. It is CMS' requirement that the shared system maintainer provide the means to achieve these goals by maximizing the use of automation and other Best Practices across the system maintenance life cycle.

Medicare's traditional Fee-for-Service (FFS) coverage consists of two distinct parts:

1. Part A hospital insurance covers expenses for medical services furnished in institutional settings, such as hospitals or skilled nursing facilities, or services provided by a home health agency or hospice, and 2. Part B supplemental medical insurance covers physician and other practitioner services; outpatient services and certain DMEPOS services.

In the 1980's CMS began the transition to a national standardization in processing. Core requirements for Medicare system contractors were established and contractors were encouraged to use standard software systems in claims processing and shared processing. The goal of these initiatives was twofold: Reduce variation in software and hardware platforms by sharing a single platform among multiple contractors, and achieve savings in system development and maintenance as well as a reduction in processing costs. The transition to standardized processing resulted in the establishment of the following:

1. Three claims processing Shared Systems: Fiscal Intermediary Shared System (FISS) for institutional Part A and B services, Multi Carrier System (MCS) for physician and other practitioner services, and Durable Medical Equipment (DME) System for DMEPOS services; 2. The Medicare eligibility system Common Working File (CWF) which provides a single data source where the contractors can verify beneficiary eligibility to receive prepayment review and approval of claims; and, 3. The single testing contractor STC, responsible for BETA testing for the shared systems and interfaces, previously referred to as Independent Testing (Contractor) (ITC), Beta testing, Quarterly Release Test Management (QRTM) and off-quarter testing of production support fixes and enhancements.

Purpose

The purpose of this contract is to obtain computer software services to support the CWF system, including maintenance, production support, developmental enhancements, and special projects as required by the CMS. The CWF system is a major component of the Medicare claims processing function within CMS. All efforts on this contract shall be performed in accordance with CMS requirements and shall meet the objectives of increasing efficiency and effectiveness of claims processing operations and timely implementation of statutory and regulatory requirements. In addition, major developmental enhancements shall meet the objective of moving current CWF software and documentation into alignment with the CMS Information Architecture planning and standards.

CWF System Overview

The CWF is a single data source for Medicare Administrative Contractors to verify beneficiary eligibility and conduct prepayment review and approval of claims from a national perspective. It is the only place in the FFS claims processing system where full individual beneficiary information is housed.

CWF has four quarterly releases that control, implement, and update software changes due to legislative mandates. Software changes for the claims processing operations are managed in quarterly releases developed through a change control process that begins with the Medicare Change Control Board (MCCB) review and prioritization of pending requests. The FFS Operations Board approves the quarterly releases with oversight by the FFS Governance Council and manages/integrates day-to-day operations of the FFS program across CMS.

This section is intended only to be a brief profile synopsis of CWF. The system and user documentation should be closely examined for further detail.

CWF software is composed of 2.4 million lines of code based upon traditional CICS online, COBOL and COBOL II batch programs, using a VSAM data structure. Processing is controlled by the following components:

1. Controller/router (prioritize actions and route claims), 2. Accept/reject process, 3. Administrative edits, 4. Part A consistency edits, 5. Part B consistency edits, 6. DMEPOS consistency edits, 7. Duplicate edits, 8. A/B Crossover edits, 9. Entitlement edits, 10. Part A utilization edits, 11. Part B utilization edits, 12. DMEPOS utilization edits, 13. Medicare Secondary Payer (MSP) consistency edits, 14. MSP utilization edits (secondary payer claims), 15. CMN utilization edits, 16. ESRD utilization edits 17. beneficiary Other Information (BOI) transactions from BCRC 18. HUEP transactions for Libby Montana project 19. Out-of-service (OSA) area claims process, 20. Beneficiary updates, 21. Unsolicited Responses (URs), and 22. Informational Unsolicited Responses (IURs).

CWF also contains the following sub-systems:

1. Medicare enrollment/updates from CMS Eligibility Data Base (EDB), 2. Incarcerated, Alien and Date of Death information from CMS EDB, 3. Part A Eligibility and query support, 4. Health Insurance Master Record (HIMR), 5. Health Insurance Correction Record (HICR), 6. Fraud Prevention System (FPS) - Claims/Denials, 7. Beneficiary Data Streamlining (BDS), 8. ORPT Reports, 9. Purge and Archive//Retrieval, 10. Internal Test Facility, and 11. Cross Reference/Merge process.

CWF as an Integral Part of Medicare Claims Processing

CMS provides oversight, guidance, and control to the Medicare claims processing operation. That function involves many complex relationships. CWF is an integral part of Medicare claims processing since claims must be validated by the CWF System.

However, many traditional claims processing functions exist outside of CWF. The following information presents an overview of the claims processing flow and distinguishes the CWF system maintained by the CWF SSM, from the claims processing activities which occur outside of the CWF system. It illustrates some of the traditional claims processing functions performed by the A/B MACs and DME MACs,

A beneficiary visits a physician, hospital, or other supplier of health care services, which, in turn, sends a bill or claim to an A/B MAC, DME MAC, (Note: clearing houses, billing agents and Part A Direct Data Entry also allow claims submission to contractors).

These A/B MAC's and DME MACs are associated with one or more CWF Hosts. An A/B MAC'S and DME MAC, will perform the traditional claims processing review and then transmit the claim to the CWF Host to which they have been assigned for verification of entitlement, utilization and deductible/co-pay information. Responses are returned to the A/B MAC'S and DME MAC, who may complete the claim adjudication, suspend, or deny the claim based on the information that the CWF system returned on the claim response. Compilation of entitlement data and maintenance of historical claims data and program liability data is performed by CMS.

This is a highly simplified illustration and does not address the more complicated aspects of the process, including explanations of benefits to beneficiaries, electronic or hard copy remittance advice to providers and post payment processing by the A/B MAC's and DME MACs. Nor does this simplified illustration address the CWF updates to the CMS central office systems such as the CWF Medicare Quality Assurance (MQA), the National Claims History (NCH) system, and the Eligibility Database (EDB systems.

The CWF system performs the following functions: 1. Provides Medicare contractors (i.e., A/B MAC's and DME MACs) with complete beneficiary information, including entitlement and utilization data and specific claims history. 2. Processes claims and returns a response within 48 hours of receipt of the claim. 3. Performs editing and validation on each claim, ensuring eligibility for payment. 4. Helps to avoid duplicate payment by comparing the claim against existing Part A, Part B and DMEPOS claims data. 5. Provides on-line response to inquiries concerning beneficiary status. 6. Checks for MSP, Medicare Advantage (MA), Home Health Agency (HHA), inpatient stays, and/or hospice involvement. 7. Provides Out Of Service Area (OSA) claims processing. 8. Provides data to National Claims History Database, the Enrollment Database, Medicare Beneficiary Database and Next Generation Desktop. 9. Situations exist where CWF processes a claim, and then receives a subsequent claim that is in conflict with the first claim. An unsolicited response is sent to the first contractor to advise them that their claim may have been processed in error. 10. Creates unsolicited responses for previously processed claims, and forwards them to the appropriate Medicare contractor. Situations exist where CWF processes a claim, and then receives a subsequent claim that is in conflict with the first claim. An unsolicited response is sent to the first contractor to advise them that their claim may have been processed in error.

Responses should include, at a minimum, the information identified in each of the following: 1. Business Information: a. Company Name; b. Company Address; c. D&B DUNS Number; d. Current GSA or GWAC contract(s) and/or schedules(s) that you possess which are appropriate to this Sources Sought; e. Does your organization have a Government approved accounting system If so, please identify the agency that approved the system; f. Type of company (e.g., small business, 8(a), veteran-owned small business, service-disabled veteran owned small business, HUB Zone small business, small disadvantaged business, and women owned small business) as validated via the System for Award Management (SAM); g. Company Point of contact (POC) name, phone and email address; and, h. POC, phone and email address of individuals who can corroborate the demonstrated capabilities identified in the responses;

NOTE: All teaming arrangements and Joint-Ventures shall also include the above-cited information and certifications for each entity on the proposed team. Teaming arrangements and Joint-Ventures are encouraged. Prime/Sub teaming arrangements, defined under FAR 9.601(2), should identified the roles for each business entity listed for each capability point, and show that the Prime has the capability and capacity to perform at least 51 percent of the work in the Prime/Sub relationship. Joint Ventures are defined by FAR 9.601(1). 2. Please describe your general overall knowledge and experience with, and/or ability to provide with teaming partners, the various programs overseen or operated by CMS. Also, please describe your experience working with CMS data systems (including shared systems) and files. 3. Please describe your general overall experience in, and/or ability to provide with teaming partners, the use of complex programing to develop shared systems that ensures maximum functionally. Please also describe techniques you have used to achieve the stated response for programing the CWF or similar system in size and scope. 4. Please describe your experience in, and/or ability to provide with teaming partners, the implementation of a shared system that runs in an IBM operating environment and uses Virtual Storage Access Method (VSAM) file structure with CICS as the data communications protocol. The experience should also be with COBOL LE; file compression and expansion, and special utility modules written in Assembler Language Code (ALC). 5. At the point of award, the awardee will have a transition onto the project. Please describe your experience in, and/or ability to provide with teaming partners, a seamless transition that insures claims processing remains uninterrupted. 6. Please describe current or past projects where your firm or teaming partners have been successful in implementing systems that support claim processing in the public or private sector. Please include a brief description of the methodology, your role in developing the methodology and the challenges you faced in implementing the project and the overall size of the project (by lines of code).

Interested parties having the capability and expertise necessary to perform the stated requirements outlined above are requested to submit capability statements via email to: [email protected] and [email protected] on or before 12:00 Noon (EST) March 14, 2016. Responses are limited to 12 pages only and should be submitted in a Word or Word comparable document. Page size should be 8.5 by 11 inches, using 12 pt. font and standard margins. While the intent of this sources sought is to determine capabilities, vendors submitting a capabilities statement, may submit a single page of questions and comments on the provided draft Statement of Work (SOW). This one page will not be counted as part of the 12 page limit for capabilities statements. Additional Information: * Proprietary Information and Disclaimers: Respondents should identify any proprietary information in its SSN response. Information submitted in response to this SSN will be used at the discretion of the Government. Further, the information submitted will remain confidential insofar as permitted by law, including the Freedom of Information and Privacy Acts. CMS reserves the right to utilize any non-proprietary technical information in the anticipated SOW or solicitation. * Responses to the SSN are not offers and cannot be accepted by CMS to form a binding contract. CMS does not intend to award a contract on the basis of this SSN, or to otherwise pay for the information solicited. No reimbursement for costs will be made associated with providing information in response to this SSN or follow-up information request. * Respondents should be aware that this SSN is for market research purposes only and any responses submitted do not constitute a commitment by CMS to treat any offeror more or less favorably in any anticipated forthcoming solicitation and/or ultimate award. * Responses to the SSN will not be returned. All communications shall be by email. * Respondents will not be notified of the results of the review of the responses. * Although it is not necessary to address within capability statements, interested vendors and teaming partners, should be aware of any potential, actual, or perceived organizational conflicts of interests. Any real or potential conflicts must be sufficiently mitigated prior to contract award. For further guidance, refer to the Federal Acquisition Regulation, Part 9.5.

Link/URL: https://www.fbo.gov/spg/HHS/HCFA/AGG/170409/listing.html