60RRBH21R0011 Attachment J.1 RRB SMAC SOW.docx
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- Attached to
- Solicitation 60RRBH21R0011 - RRB Specialty MAC
- Solicitation number
- 60RRBH21R0011
- Issued by
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Railroad Retirement Board
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RFP 60RRBH21R0011 Attachment J.1
Part B Railroad Specialty Medicare Administrative Contractor
Attachment J.1 - Statement of Work (SOW) for Solicitation RFP 60RRBH21R0011
Source Selection Information – See FAR 2.101 and 3.104
| C.1 SCOPE | 1 |
| C.1.1 Purpose of Contract | 1 |
| C.1.2 Background | 2 |
| C.1.3 Contracting Reform | 4 |
| C.1.4 Roles and Responsibilities | 4 |
| C.1.4.1 The Centers for Medicare & Medicaid Services and the Railroad Retirement Board | 4 |
| C.1.4.1.1 Business Function Leads and Technical Monitors | 5 |
| C.1.4.2 Medicare Administrative Contractor (“The Contractor”) | 5 |
| C.1.4.3 Jurisdiction-Specific Requirements | 6 |
| C.1.4.4 Reserved | 6 |
| C.2 APPLICABLE DOCUMENTS | 6 |
| C.2.1 Statutes | 6 |
| C.2.1.1 Social Security Act (Public Law 74-271) | 7 |
| C.2.1.2 Medicare Prescription Drug, Improvement, and Modernization Act (MMA) (Public Law 108-173) | 7 |
| C.2.1.3 The Health Insurance Portability and Accountability Act of 1996 (Public Law 104-191) | 8 |
| C.2.1.4 Administrative Simplification Compliance Act of 2002 (Public Law 107-105) | 8 |
| C.2.1.5 The Tax Equity and Fiscal Responsibility Act of 1982 (Public Law 97-248) | 8 |
| C.2.1.6 Benefits Improvements and Protection Act of 2000 (Public Law 106-554) | 8 |
| C.2.1.7 Executive Order 13410 | 9 |
| C.2.2 Regulations | 9 |
| C.2.3 Medicare Manuals | 9 |
| C.3 KEY DEFINITIONS | 10 |
| C.4 OBJECTIVES | 10 |
| C.4.1 Customer Service | 10 |
| C.4.2 Operational Excellence | 11 |
| C.4.3 Innovation and Technology | 11 |
| C.4.4 Financial Management | 11 |
| C.5 FUNCTIONAL REQUIREMENTS | 12 |
| C.5.1 Workload Implementation Requirements | 12 |
| C.5.1.1 Implementation Project Plan | 13 |
| C.5.1.2 Cutover Project Plan | 13 |
| C.5.1.3 Risk Management Plan | 13 |
| C.5.1.4 Implementation Stakeholder Communication | 13 |
| C.5.1.5 Operational Start Date (OSD) | 14 |
| C.5.1.6 Implementation Meetings | 14 |
| C.5.1.7 Accounts Receivable Reconciliation | 15 |
| C.5.2 Workload Closeout Project Plan (Option that may be exercised at the End of the Contract) | 15 |
| C.5.2.1 Workload Closeout Project Plan (Option that may be exercised at end of the contract) | 15 |
| C.5.2.2 Workload Closeout Meetings (Option that may be exercised at end of the contract) | 16 |
| C.5.2.3 Workload Closeout Risk Management Plan (Option that may be exercised at end of the contract) | 16 |
| C.5.2.4 Accounts Receivable Reconciliation (Option that may be exercised at end of the contract) | 16 |
| C.5.2.5 Cost Accounting/Audit (Option that may be exercised at the End of the Contract) | 16 |
| C.5.3 Infrastructure Requirements | 17 |
| C.5.3.1 Virtual Data Center | 17 |
| C.5.3.1.1 Local Hardware and Software Requirements | 19 |
| C.5.3.1.1.1 Translation Software | 19 |
| C.5.3.1.1.2 Reserved | 20 |
| C.5.3.1.2 Reserved | 20 |
| C.5.3.2 Telecommunications | 20 |
| C.5.3.2.1 Telecommunications for Electronic Data Interchange | 22 |
| C.5.3.2.1.1 Electronic Data Interchange Enrollment Form | 23 |
| C.5.3.2.1.2 Transaction Error Reporting | 24 |
| C.5.3.2.1.3 Receipt of Electronic Data Interchange Transactions | 24 |
| C.5.3.2.1.4 Sending Electronic Data Interchange Transactions | 24 |
| C.5.3.2.1.5 Automated Clearing House transactions | 25 |
| C.5.3.2.1.6 Direct Data Entry Capability | 25 |
| C.5.3.2.1.7 Initial Edits | 25 |
| C.5.3.2.1.8 Combined Common Edits and Enhancement Module | 26 |
| (CCEM) Software – Edits | 26 |
| C.5.3.2.2 Electronic Data Interchange Help Desk | 27 |
| C.5.3.2.3 Reserved | 27 |
| C.5.3.2.4 HIPAA Code Set Updates | 28 |
| C.5.3.2.5 Claim Adjustment Reason Codes (CARC)/Remittance Advice Remark Code (RARC) | 28 |
| C.5.3.3 Telephone Service | 28 |
| C.5.3.4 RRB/CMS Audits and Reviews | 28 |
| C.5.4 Administrative Requirements | 28 |
| C.5.4.1 Key Personnel Requirements | 28 |
| C.5.4.1.1 Project Manager | 29 |
| C.5.4.1.2 Claims Processing Manager | 29 |
| C.5.4.1.3 Chief Financial Officer (CFO) | 29 |
| C.5.4.1.4 Compliance Officer | 30 |
| C.5.4.1.5 Medicare Benefit Integrity Manager | 30 |
| C.5.4.1.6 Chief Information Officer (CIO) | 30 |
| C.5.4.1.7 Systems Security Officer (SSO) | 30 |
| C.5.4.1.8 Implementation Project Director | 31 |
| C.5.4.1.9 Provider and Beneficiary Customer Service Program (PBCSP) Manager | 31 |
| C.5.4.1.10 Contract Administrator | 31 |
| C.5.4.1.11 Medical Director | 32 |
| C.5.4.2 Specialty MAC Program Management Office (PMO) Responsibilities | 33 |
| C.5.4.2.1 Post Award Meeting | 33 |
| C.5.4.2.2 Monthly Status Report and Operational Status Conference Calls | 34 |
| C.5.4.2.3 Reserved | 35 |
| C.5.4.2.4 Ad Hoc Reporting | 35 |
| C.5.4.2.5 Task Directives | 35 |
| C.5.4.2.6 Reserved | 35 |
| C.5.4.2.7 Voucher/Financial Management System | 35 |
| C.5.4.2.8 RRB/CMS Reporting Requirements | 36 |
| C.5.4.2.8.1 Reserved | 36 |
| C.5.4.2.8.2 CROWD | 36 |
| C.5.4.2.8.3 Provider Inquiries Evaluation System (PIES) | 36 |
| C.5.4.2.8.4 Provider Customer Service Program Contractor Information Database (PCID) | 36 |
| C.5.4.2.8.5 Physician and Supplier Overpayment and Recovery System (PSOR) | 37 |
| C.5.4.2.8.6 Delinquent Debt Collection System (DCS) | 37 |
| C.5.4.2.8.7 Medicare Exclusion Database (MED) | 37 |
| C.5.4.2.8.8 Quality Call Monitoring (QCM) | 37 |
| C.5.4.2.8.9 Quality Written Correspondence Monitoring (QWCM) | 37 |
| C.5.4.2.8.10 Reserved | 37 |
| C.5.4.2.8.11 Reserved | 37 |
| C.5.4.2.9 Administrative Simplification Compliance Act (ASCA) Enforcement and Reporting | 38 |
| C.5.4.2.10 Freedom of Information Act Requests | 38 |
| C.5.4.2.11 Operational Productivity Report | 39 |
| C.5.4.3 Security | 39 |
| C.5.4.3.1 Certification by Chief Information Officer for Compliance with CMS Systems Security Requirements | 39 |
| C.5.4.3.2 Administer Security Program | 39 |
| C.5.4.3.3 Access to Systems | 40 |
| C.5.4.3.3.1 Reserved | 40 |
| C.5.4.3.3.2 Other Systems Access Requirements | 40 |
| C.5.4.3.4 Correct Deficiencies | 40 |
| C.5.4.3.4.1 Corrective Action Attestation | 41 |
| C.5.4.3.5 Security Review and Verification | 41 |
| C.5.4.4 Quality Assurance Requirements | 41 |
| C.5.4.4.1 Quality Control Program | 42 |
| C.5.4.4.2 Reserved | 44 |
| C.5.4.4.3 Reserved | 44 |
| C.5.4.5 Public Relations | 44 |
| C.5.4.5.1 Medicare Beneficiary Ombudsman | 45 |
| C.5.4.5.2 RRB Regional and Local Office Liaison | 45 |
| C.5.4.5.2.1 Urgent Need RRB Office Casework | 45 |
| C.5.4.5.3 Reserved | 45 |
| C.5.4.6 Congressional inquiries | 45 |
| C.5.4.6.1 Responses to Congressional Inquiries | 45 |
| C.5.4.6.2 Congressional Outreach and Education | 46 |
| C.5.4.7 Participation in Conferences, Meetings, and Work Groups | 46 |
| C.5.4.7.1 Participation in Conferences | 46 |
| C.5.4.7.1.1 CMS Financial Management Training Conference | 47 |
| C.5.4.7.2 Participation in Meetings and Workgroups | 47 |
| C.5.4.7.3 Support Income Tax Reporting | 47 |
| C.5.4.8 Participation in Change Management Process | 48 |
| C.5.4.8.1 Review and Comment on Draft Change Requests | 50 |
| C.5.4.8.1.1 Level of Effort Assessments | 50 |
| C.5.4.8.2 Early Involvement | 52 |
| C.5.4.8.3 Successful Implementation of Change Requests | 53 |
| C.5.4.8.3.1 Walkthroughs | 54 |
| C.5.4.8.4 Participate in Testing Changes to Systems | 55 |
| C.5.4.8.5 Successful Post-Implementation Operation | 56 |
| C.5.4.9 Continuity of Operations Planning | 56 |
| C.5.4.10 Internal Controls | 56 |
| C.5.4.10.1 Written Policies and Procedures | 57 |
| C.5.4.10.2 Self-Assessment Process for Internal Controls | 57 |
| C.5.4.10.3 Correcting Internal Control Deficiencies – Corrective Action Plan Process | 57 |
| C.5.4.10.4 Statement on Standards for Attestation Engagements 18 (SSAE 18) Audit | 58 |
| C.5.4.11 Compliance Program | 59 |
| C.5.5 Reserved | 59 |
| C.5.6 Reserved | 59 |
| C.5.7 Reserved | 60 |
| C.5.8 Claims Processing | 60 |
| C.5.8.1 Standard Paper Remittance Advice Transactions | 60 |
| C.5.8.1.1 Reserved | 60 |
| C.5.8.2 General Claims Processing | 61 |
| C.5.8.2.1 Communication of Claims Processing Problems | 62 |
| C.5.8.2.2 Resolution of CWF Rejected Claims Involving another MAC | 62 |
| C.5.8.2.3 Resolution of Claims Transaction Replies from Common Working File | 62 |
| C.5.8.2.4 Resolution of Unsolicited Responses from Common Working File | 62 |
| C.5.8.2.5 Payment of Claims outside Common Working File | 63 |
| C.5.8.2.6 Reserved | 63 |
| C.5.8.2.7 Local System Edits | 63 |
| C.5.8.3 Manage Paper Claims | 63 |
| C.5.8.3.1 Receipt, Conversion, and Control | 63 |
| C.5.8.3.2 Electronic Data Interchange (EDI) Support Related to Front-end Paper Claims and Transactions | 64 |
| C.5.8.3.3 Quality Control Checks | 64 |
| C.5.8.3.4 Reserved | 64 |
| C.5.8.4 Development of Suspended Claims | 64 |
| C.5.8.5 Back-End Processing of Claims | 64 |
| C.5.8.5.1 Remittance Advice and Medicare Summary Notices | 65 |
| C.5.8.5.2 Coordination of Benefits Flat Files | 65 |
| C.5.8.5.3 Generate and Mail Claims Processing Documents | 66 |
| C.5.8.5.4 The Do Not Forward Initiative | 66 |
| C.5.8.6 Opt-Out Payment Provisions | 67 |
| C.5.8.7 Incentive Payments | 67 |
| C.5.8.7.1 Physician Incentive Payments for Services in Health Professional Shortage Area and Physician Scarcity Area | 67 |
| C.5.8.7.2 Physician Quality Reporting System (PQRS) | 67 |
| C.5.8.7.3 Electronic Prescribing Initiative | 68 |
| C.5.8.7.4 Primary Care Incentive Payment Program | 68 |
| C.5.9 Reopening of Medicare Initial Claims Determinations | 68 |
| C.5.9.1 Reopening | 68 |
| C.5.9.1.1 Reopenings on the Contractor’s Own Motion | 68 |
| C.5.9.1.2 Reopenings on the Request of a Party | 69 |
| C.5.9.1.2.1 Clerical Error Reopenings | 69 |
| C.5.9.1.2.2 Reserved | 69 |
| C.5.9.1.2.3 Documentation Requests | 69 |
| C.5.9.1.3 Reopening Appeal Cases | 69 |
| C.5.9.2 Establishing Good Cause for Reopening Initial Determinations and Redeterminations | 69 |
| C.5.9.3 Reopening Decisions | 70 |
| C.5.10 Appeals of Medicare Initial Claims Determinations | 70 |
| C.5.10.1 Redetermination Requests | 70 |
| C.5.10.1.1 Controlling Receipt of Correspondence | 70 |
| C.5.10.1.2 Document Imaging and Indexing | 70 |
| C.5.10.1.3 Acceptance of Valid Redetermination Requests | 70 |
| C.5.10.1.3.1 Confirmation of Receipt of Redetermination Requests | 71 |
| C.5.10.1.4 Misfiled Appeal Requests | 71 |
| C.5.10.1.5 Granting of Extensions for Late Redetermination Requests and Determination of Good Cause | 71 |
| C.5.10.1.6 Consolidation of Multiple Requests for Same Claim | 71 |
| C.5.10.1.7 Withdrawals and Eligibility-Based Dismissals | 71 |
| C.5.10.1.8 Assistance to Beneficiary | 72 |
| C.5.10.1.9 Conduct and Notice of the Redetermination | 72 |
| C.5.10.1.10 Documenting the Redetermination Case Files | 74 |
| C.5.10.2 Appeal Decision Effectuation | 74 |
| C.5.10.3 Monthly Statistical Report on Reopening and Appeals Activities (CMS – 2592 & CMS 2590/2591) | 74 |
| C.5.10.4 Reserved | 75 |
| C.5.10.5 Reserved | 75 |
| C.5.10.5.1 Reserved | 75 |
| C.5.10.5.2 Reserved | 75 |
| C.5.10.5.3 Reserved | 75 |
| C.5.10.5.4 Reserved | 75 |
| C.5.10.6 Qualified Independent Contractor (QIC) | 75 |
| C.5.10.6.1 Supply Appeals Case Files for QICs | 75 |
| C.5.10.7 Preparation of Case Files | 75 |
| C.5.11 Provider and Beneficiary Customer Service Program | 76 |
| C.5.11.1 Provider Customer Service Program | 76 |
| C.5.11.1.2 Provider Outreach and Education | 76 |
| C.5.11.1.2.1 Data Analysis | 77 |
| C.5.11.1.2.2 Reserved | 77 |
| C.5.11.1.2.3 Provider Organization Partnerships | 77 |
| C.5.11.1.2.4 Promotion of Internal Communication and Development of Provider Issues | 77 |
| C.5.11.1.2.5 Bulletin/Newsletter Publication | 77 |
| C.5.11.1.2.6 “Ask-the-Contractor” Teleconferences/Webinars | 77 |
| C.5.11.1.3 Provider Service Plan | 78 |
| C.5.11.1.4 Provider Customer Service Program Activity Report | 78 |
| C.5.11.1.5 Provider Contact Center | 78 |
| C.5.11.1.5.1 Telephone Inquiries | 78 |
| C.5.11.1.5.2 Written Inquiries | 79 |
| C.5.11.1.5.3 Congressional Inquiries Timeliness | 80 |
| C.5.11.1.6 Provider Relations Research Specialists | 81 |
| C.5.11.1.7 Inquiry Tracking System | 81 |
| C.5.11.1.8 Provider Self-Service Technology | 82 |
| C.5.11.1.8.1 Interactive Voice Response | 82 |
| C.5.11.1.8.2 Web Technology | 83 |
| C.5.11.1.8.2.1 Reserved | 83 |
| C.5.11.1.9 Provider Electronic Mailing List | 83 |
| C.5.11.1.10 PCSP Staff Training | 83 |
| C.5.11.1.11 Medicare Customer Experience | 83 |
| C.5.11.1.12 Provider Internet Portal | 84 |
| C.5.11.2 Railroad Medicare Beneficiary Contact Center | 84 |
| C.5.11.2.1 Telephone Inquiries | 85 |
| C.5.11.2.2 Inquiry Types | 85 |
| C.5.11.2.2.1 General Railroad Medicare Inquiries | 85 |
| C.5.11.2.2.2 Claim Inquiries | 86 |
| C.5.11.2.3 Written Inquiries | 87 |
| C.5.11.2.4 Functional Requirements | 87 |
| C.5.11.2.5 Responding to Complex Beneficiary Inquiries | 88 |
| C.5.11.2.5.1 Acceptance and Tracking of Complex Beneficiary Inquiry Referrals | 90 |
| C.5.11.2.5.2 Second Level Screenings | 90 |
| C.5.11.2.6 English, Spanish, and Text Telephone Capabilities | 90 |
| C.5.11.2.7 Review Written Responses for Reading Level (Fogging) Accuracy and Timeliness | 90 |
| C.5.11.2.8 Reserved | 90 |
| C.5.11.2.9 Reserved | 90 |
| C.5.11.2.10 Reserved | 90 |
| C.5.11.2.11 BCC Staff Training | 90 |
| C.5.11.2.12 Reserved | 91 |
| C.5.11.2.12.1 Reserved | 91 |
| C.5.11.2.12.2 Reserved | 91 |
| C.5.11.2.13 Reserved | 91 |
| C.5.11.2.14 Reserved | 91 |
| C.5.11.2.15 Feedback | 91 |
| C.5.11.2.16 Reserved | 91 |
| C.5.11.2.17 Beneficiary Satisfaction Survey | 91 |
| C.5.12 Provider Enrollment | 91 |
| C.5.12.1 Electronic Funds Transfer Authorization Agreement | 92 |
| C.5.13 Financial Management of Trust Fund Dollars | 92 |
| C.5.13.1 Use of Trust Fund | 93 |
| C.5.13.1.1 Certification of Financial Reporting by Chief Financial Officer for Medicare Operations | 93 |
| C.5.13.1.2 Validation of Financial Data | 93 |
| C.5.13.1.3 Resolution of Financial Deficiencies | 93 |
| C.5.13.2 Banking Relations | 93 |
| C.5.13.2.1 Reserved | 94 |
| C.5.13.2.2 Account Services Analysis | 94 |
| C.5.13.2.3 Benefits Account | 94 |
| C.5.13.2.4 Account Reconciliation | 94 |
| C.5.13.2.4.1 Cash Collections Worksheet | 95 |
| C.5.13.2.4.2 Estimated Allowance for Uncollectible Accounts | 95 |
| C.5.13.2.5 Letter-of-Credit Limitation | 95 |
| C.5.13.3 Reserved | 95 |
| C.5.13.4 Non-Medicare Secondary Payer Overpayment | 95 |
| C.5.13.4.1 Recovery of Overpayments | 96 |
| C.5.13.4.2 Applications for Extended Repayment Schedule | 96 |
| C.5.13.4.3 Limitation on Recoupment (935) for Providers, Physicians and other Suppliers Overpayments | 96 |
| C.5.13.4.4 Reserved | 97 |
| C.5.13.5 Non-Medicare Secondary Payer Debt Collection Activities | 97 |
| C.5.13.6 Non-Medicare Secondary Payer Debt Referral | 97 |
| C.5.13.6.1 Non-Medicare Secondary Payer Debt Collection Improvement Act Intent to Refer Letter | 97 |
| C.5.13.6.2 Non-Medicare Secondary Payer Debt Referral Inquiries | 98 |
| C.5.13.6.3 Debt Collection System Database | 98 |
| C.5.13.6.4 Posting of Debts Collected by Treasury | 98 |
| C.5.13.6.5 Posting of Debts Returned to Agency by Treasury | 98 |
| C.5.13.7 Unsolicited/Voluntary Refunds | 98 |
| C.5.13.8 Overpayment Related To Bankruptcy | 99 |
| C.5.13.8.1 Administrative Freeze Payments | 100 |
| C.5.13.8.2 Closed Bankruptcy Case | 100 |
| C.5.13.9 Financial Reporting and Accounting | 100 |
| C.5.13.9.1 Accounts Receivable Trend Analyses | 100 |
| C.5.13.9.2 Financial Reporting Audits/Reviews | 101 |
| C.5.13.9.3 Other Financial System Controls | 101 |
| C.5.13.10 Medicare Credit Balance Report Activities | 101 |
| C.5.14 Medical Review | 102 |
| C.5.14.1 Medical Review of Claims | 102 |
| C.5.14.2 Development of Annual Improper Payment Reduction Strategy | 102 |
| C.5.14.2.1 Improper Payment Reduction Activities Report | 103 |
| C.5.14.3 Medical Review Data and Activity Definitions | 103 |
| C.5.14.3.1 Medical Review Data: Data Analysis | 103 |
| C.5.14.3.2 Medical Review Data: Edit Effectiveness | 104 |
| C.5.14.3.3 Reserved | 104 |
| C.5.14.3.4 Reserved | 104 |
| C.5.14.3.5 Automated Medical Review | 104 |
| C.5.14.3.6 Non-Medical Record Review | 104 |
| C.5.14.3.7 Medical Review Reopening | 104 |
| C.5.14.3.8 Prepay Provider Specific Medical Record Review | 105 |
| C.5.14.3.9 Prepay Service Specific Medical Record Review | 105 |
| C.5.14.3.10 Prepay Provider Specific Probe Medical Record Review | 105 |
| C.5.14.3.11 Prepay Service Specific Probe Medical Record Review | 105 |
| C.5.14.3.12 Postpay Provider Specific Probe Medical Record Review | 106 |
| C.5.14.3.13 Postpay Service Specific Probe Medical Record Review | 106 |
| C.5.14.3.14 Postpay Provider Specific Medical Record Review | 107 |
| C.5.14.3.15 Postpay Service Specific Medical Record Review | 107 |
| C.5.14.3.16 Medical Review Edit Development | 107 |
| C.5.14.4 Quality Assurance and Improvement | 107 |
| C.5.14.5 Support of Comprehensive Error Rate Testing | 107 |
| C.5.14.6 Monthly Reporting of Medical Review Savings | 108 |
| C.5.14.7 One-on-One Education | 108 |
| C.5.14.8 Defending Medical Review Decisions at Administrative Law Judge Hearings | 108 |
| C.5.14.8.1 Coordination | 109 |
| C.5.14.8.2 Reserved | 109 |
| C.5.14.8.3 Reserved | 109 |
| C.5.14.8.4 Reserved | 109 |
| C.5.15 Benefit Integrity | 109 |
| C.5.15.1 Support of Benefit Integrity | 110 |
| C.5.15.2 Benefit Integrity Staff Personnel | 111 |
| C.5.15.2.1 Reserved | 111 |
| C.5.15.2.2 Fraud Investigator | 111 |
| C.5.15.2.3 Fraud Analyst | 111 |
| C.5.15.2.4 Medical Reviewer | 112 |
| C.5.15.3 Reserved | 112 |
| C.5.15.4 Investigation Requirements | 112 |
| C.5.15.5 Immediate Advisements to the OIG/OI | 112 |
| C.5.15.6 Case Requirements | 113 |
| C.5.15.7 Payment Suspension Requirements | 113 |
| C.5.16 Medicare Secondary Payer | 113 |
| C.5.16.1 Implementation of Medicare Secondary Payer Operations | 115 |
| C.5.16.2 Electronic Correspondence Referral System Status Inquiries | 115 |
| C.5.16.3 Medicare Secondary Payer Claims Payment Determinations | 115 |
| C.5.16.4 Medicare Secondary Payer Claims Adjudication and Validation | 115 |
| C.5.16.5 Medicare Secondary Payer Claims Inquiries | 115 |
| C.5.16.6 MSP Claim with Complete Explanation of Benefits (EOB): Update CWF | 116 |
| C.5.16.7 Incomplete EOB: Possible MSP Claim, Possible MSP Situation, or CWF Exclusion: Forward to BCRC | 116 |
| C.5.16.8 Transfer of Documentation and Phone Calls to the Benefits Coordination and Recovery Center | 116 |
| C.5.16.9 Medicare Secondary Payer Post Payment Recovery | 116 |
| C.5.16.9.1 Duplicate Primary Payments | 117 |
| C.5.16.9.2 Inquiries Specific to Debt Collection Efforts for Providers, Physicians and other Suppliers | 118 |
| C.5.16.9.3 Debt Collection Referral Activities for Providers, Physicians and other Suppliers | 118 |
| C.5.16.9.4 MSP Savings Report | 118 |
| C.5.16.9.5 Misrouted BCRC MSP Checks (Non-GHP) and/or Misrouted CRC MSP Recovery Checks (GHP) | 118 |
| C.5.16.9.6 Misrouted BCRC MSP Correspondence Non-GHP and/or GHP | 119 |
| C.5.17 Reserved | 120 |
| C.5.18 Reserved | 120 |
| C.5.19 Reserved | 120 |
| C.5.20 Shipboard/Foreign Travel Services | 120 |
| C.5.21 Foreign Claims | 120 |
| C.6 INTERFACE REQUIREMENTS | 120 |
| C.6.1 Successful Collaboration with Entities Requiring Joint Operating Agreements | 121 |
| C.6.1.1 Joint Operating Agreement: Administrative Qualified Independent Contractor (AdQIC) | 122 |
| C.6.1.2 Joint Operating Agreement: Beneficiary and Family Centered Care Quality Improvement Organizations (BFCC-QIOs) | 122 |
| C.6.1.2.1 Reserved | 122 |
| C.6.1.2.2 Reserved | 122 |
| C.6.1.2.3 Reserved | 122 |
| C.6.1.2.4 Reserved | 122 |
| C.6.1.2.5 Reserved | 122 |
| C.6.1.2.6 Reserved | 122 |
| C.6.1.3 Joint Operating Agreement: Call Center Operations | 123 |
| C.6.1.4 Joint Operating Agreement: VDC | 123 |
| C.6.1.5 Joint Operating Agreement: Qualified Independent Contractor | 123 |
| C.6.1.6 Joint Operating Agreement: Benefits and Coordination Recovery Center (BCRC) | 123 |
| C.6.1.7 Joint Operating Agreement: Commercial Repayment Center (CRC) | 123 |
| C.6.1.8 Joint Operating Agreement: Unified Program Integrity Contractor (UPIC) | 124 |
| C.6.2 Successful Collaboration and Coordination with Other Internal and External Agencies | 124 |
| C.6.2.1 Investigative Agencies | 124 |
| C.6.2.1.1 Access to Files, Records, Data, and Personnel | 124 |
| C.6.2.1.2 Search Warrants | 125 |
| C.6.2.2 RRB Field Offices and CMS Regional Offices | 125 |
| C.6.2.3 Medicare Advantage Plans, Prescription Drug Plans, and Nontraditional Fee-for-Service Entities | 125 |
| C.6.2.4 Other Medicare Administrative Contractors | 125 |
| C.6.2.5 Contractor Coordination with Private Fee for Service | 125 |
| C.6.2.6 Professional Associations | 125 |
| C.6.2.7 Infrastructure Service Providers | 125 |
| C.6.2.8 Bank Interface | 126 |
| RFP 60RRBH21R0011 | Attachment J.1 |
C.1 SCOPE
The Contractor, as an independent Contractor and not as an agent of the government, shall furnish all the necessary services, qualified personnel, material, equipment, and facilities, not otherwise provided by the government, as needed to perform the work described in this Statement of Work (SOW).
The Contractor shall perform all Medicare Administrative Contractor (MAC) Part B functions on behalf of Railroad Retirement Board (RRB) Medicare beneficiaries as specified in this SOW and as further defined in either the Internet-Only-Manuals (IOMs), https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs.html) or the Paper-Based Manuals. For purposes of this contract, when differences or conflicts occur, this SOW shall take precedence over the IOMs and Paper-Based Manuals, unless otherwise specified. The Contractor shall contact the Contracting Officer (CO) and the Contracting Officer’s Representative (COR) if budgetary concerns occur because of this conflict. The Contractor is advised that any and all references in the SOW (including manuals, IOMs, etc.) to Regional Office (RO) shall be replaced with “CO” unless otherwise specified in this SOW. Appendix A (see Request for Proposal (RFP) attachment J.1.B) contains definitions of the abbreviations and acronyms used in this SOW.
C.1.1 Purpose of Contract The purpose of this contract is to obtain a RRB Specialty Medicare Administrative Contractor (hereinafter, referred to as “the Contractor” or “RRB SMAC”) to provide specified health insurance benefit administration services, including Medicare Part B claims processing and payment services, in support of the Medicare fee-for-service (FFS) program. The Contractor will perform its responsibilities under the direction of the RRB and guidance from the Centers for Medicare & Medicaid Services (CMS) to process all Medicare Part B claims and related workloads submitted on behalf of RRB Medicare beneficiaries nationwide.
Under this contract, the Contractor will perform numerous functions to support health care services for RRB Medicare beneficiaries nationwide, which include performing claims-related activities and establishing relationships with providers of health care professional services. The Contractor will 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 program. The Medicare program’s legal, policy, and operating environment is complex, and the Contractor will utilize or interact with certain 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 the RRB and CMS, but also with a broad range of agencies (at the federal, state, and local levels of government), other RRB and CMS partners and Contractors, and a diverse range of stakeholders within the health care system of the United States.
The Contractor will receive and control Part B Medicare claims for RRB Medicare beneficiaries nationally from professional providers and beneficiaries and will perform standard or required editing on these claims to determine whether the claims are complete and should be paid. In addition, the Contractor will calculate Medicare payment amounts and arrange for remittance of these payments to the appropriate party. The Contractor will validate provider enrollment in CMS’s Provider Enrollment Chain Ownership System (PECOS) through the Provider Enrollment System (PES); conduct redeterminations on appeals of claims; operate a nationwide Provider Customer Service Program (PCSP) that educates providers about the Medicare program’s rules, regulations and billing procedures; respond to provider electronic, telephone and written inquiries; provide efficient operations of a virtual contact center to handle RRB beneficiary Medicare inquiries nationwide. The Contractor’s center will also interact with the 1(800) Medicare call center when appropriate. The RRB SMAC contractor will perform Benefit Integrity (BI) activities outlined in this SOW (see Section C.5.15).
The mission of the RRB is to ensure health care security for its beneficiaries. This contract specifically applies to that mission by fostering excellence in the design and administration of the Railroad Medicare program.
C.1.2 Background The Medicare program is an integral component of the federal government’s commitment to the health and welfare of the American people, which includes the Social Security system, the Medicaid program (which is primarily administered by the states), and other programs. The Medicare program provides affordable health insurance to (1) eligible individuals aged 65 and over; (2) certain individuals eligible for disability benefits under the Social Security system; and (3) individuals with acute kidney failure (End Stage Renal Disease, or ESRD). Nearly all Medicare beneficiaries may access their insurance benefits through one of two health care delivery systems.
First, in all areas of the country, a beneficiary may enroll in the traditional Medicare program (the Medicare FFS program) under which benefits are largely provided in keeping with an indemnity insurance model. That is, the beneficiary chooses his/her health care providers, the provider bills for its services to the appropriate Medicare claims administrator for their services, and the claims administrator pays the based on the Medicare Hospital Insurance (HI) and/or Supplementary Medical Insurance (SMI) program’s eligibility, coverage and payment rules. The federal government bears all financial (underwriting) risk for the cost of program benefits under this program, and develops detailed administrative requirements and processes to support the claim administration process. This national entitlement program has strong imperative to provide a common level of benefits and service in all areas of the country while maintaining adequate flexibility to account for local and regional medical practices. Second, in many areas of the country, beneficiaries have the option to enroll in one or more privately-sponsored Medicare plans under the Medicare Advantage (MA, formerly Medicare+ Choice) program. These private Medicare plans may organize themselves in keeping with one of several health care delivery and payment models (health maintenance organizations, preferred provider organizations, etc.). These private Medicare plans are required to cover the same basic benefits that the traditional Medicare program offers, but they are given fairly broad responsibility and latitude to set up their internal requirements and processes as they see fit.
The RRB is the federal agency created under the Railroad Retirement Act (RRA) and the Railroad Unemployment Insurance Act (RUIA). The RRB’s primary function is to administer comprehensive retirement, survivor, unemployment and sickness benefit programs for the nation’s railroad workers and their families. Medicare covers qualified railroad retirement beneficiaries just as it covers Social Security beneficiaries. However, in connection with the retirement program, the RRB maintains the administrative responsibilities under the Social Security Act for railroad retirement annuitants’ Medicare Part B eligibility and benefit payments.
The CMS historically contracted with insurance companies to process Medicare claims and perform related support functions, based on geographic territories. The majority of Medicare beneficiaries had their Part B claims processed by insurance carriers under contract with CMS.
Those who qualify for Medicare under the RRA are an important exception. By statute, the RRB has separate authority to contract for the handling of physician and other Part B claims through a contractor that services railroad retirement annuitants only.
An agreement between the RRB and the Social Security Administration dated May 11, 1966, delegated responsibility and authorized reimbursement to the RRB for enrolling retired and non-retired railroad employees, their spouses, and disabled children in Supplemental Medical Insurance benefits, collecting cash premiums for those benefits, contracting with a contractor to process SMI claims, advising beneficiaries on SMI benefits, and recovering Hospital and SMI overpayments.
The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) includes significant incentives to increase the participation in MA. FFS coverage in the Medicare Program consists of two distinct parts: (1) HI, which also provides coverage for Medicare institutional benefits and is outside the scope of Part B services under this contract; and, (2) SMI, which provides coverage for the professional medical services of physicians and certain other licensed practitioners, as well as coverage for a variety of other services and items (ambulance, durable medical equipment, etc.). In common usage, the HI program is known as “Medicare Part A,” although both the Part A and B trust funds are used to reimburse institutional claims. The SMI program is known as “Medicare Part B,” and only the Medicare Part B trust fund is used to reimburse Part B claims.
Medicare spending – both HI and SMI – is a substantial portion of the federal government’s annual budget and the health care economy of the United States.
C.1.3 Contracting Reform On December 8, 2003, the President signed into law the MMA (Public Law 108-173). Section 911 of MMA directed the implementation of Medicare FFS Contracting Reform. Medicare Contracting Reform (MCR) required that the CMS use competitive procedures to replace the prior Medicare FFS claims contractors (the Fiscal Intermediaries (FIs) and carriers) with a uniform type of administrative entity, referred to as a MAC. The RRB’s administrative entity is referred to as the RRB Specialty MAC (RRB SMAC).
C.1.4 Roles and Responsibilities The roles and responsibilities of the parties are outlined below.
C.1.4.1 The Centers for Medicare & Medicaid Services and the Railroad Retirement Board The Medicare program’s authorizing statutes charge the Secretary of the Department of Health and Human Services (DHHS) with administrative responsibility for the Medicare program. The Secretary has delegated the program authority for Medicare (both the traditional FFS program and MA) to the CMS Administrator.
The CMS administers the Medicare Program, including formulation and promulgation of Medicare Program policy and guidance, contract execution, operation and management, maintenance and review of utilization records, and general Medicare financing. The CMS is the largest purchaser of health care in the United States and provides health care coverage to nearly one in four Americans. The CMS’s annual budget places it among the largest payment operations in the world; its programs channel one out of every three dollars in the health care market and its policies influence the other two dollars.
As part of its responsibility to administer the Railroad Medicare program, the RRB, in coordination and cooperation with CMS, manages the work of its respective Contractor engaged in day-to-day Medicare operation. This management is accomplished through a variety of avenues such as periodic conferences on topics of general interest; targeted sessions with selected subsets of the Contractor; issuance of manual updates describing changes in coverage, pricing, and eligibility; and evaluation of the performance of the Contractor within the description of the work it has been engaged to do. An exception to CMS jurisdictional authority is the RRB. This exception is explained in detail in Section C.1.2.
C.1.4.1.1 Business Function Leads and Technical Monitors Within the CMS, specialists on various Medicare topics shall serve as Business Functional Leads (BFLs) and Technical Monitors (TMs) to assist the COR and the CO in administering the contract. The RRB, when necessary, uses these BFLs and TMs to provide technical guidance on matters within each BFL’s and/or TM’s area of responsibility as it relates to our Contractor’s performance.
The RRB SMAC shall support the RRB and its field offices in their efforts to support CMS and combat fraud, waste or abuse of the Medicare program and protect the Medicare Trust Fund.
C.1.4.2 Medicare Administrative Contractor (“The Contractor”) Section 1861 of the Social Security Act (“the Act”) defines the items and services for which Medicare may pay. It also defines the provider types recognized by the Medicare program. The Contractor is responsible for handling all Part B claims identified in the Act that are within its jurisdiction The complexity of Medicare payment systems and policies, and the numbers of contractors, providers, and insurers involved in the Medicare FFS program create vulnerabilities for error. To minimize these vulnerabilities and reduce the Medicare claims payment error rate, the RRB supports paying claims right the first time, this is one of CMS’s primary goals. This means paying the right amount, to legitimate providers, for Medicare–covered, reasonable and necessary services provided to eligible beneficiaries. Paying right the first time saves resources required to recover improper payments and ensures the proper expenditure of valuable Medicare trust fund dollars.
In the interest of consistency across the Medicare program, during the performance of this contract, the Contractor is expected to seek advice from CMS on questions of law and policy as they arise.
Information relating to Part B MAC claims processing, information flows, interfaces and other supporting processes with “functional Contractors” can be found in both the Concept of Operations document located at the following Uniform Resource Locator (URL): http://www.cms.gov/Medicare/Medicare-Contracting/Medicare-Administrative-Contractors/Downloads/Functional-Contractors-Overview-2013.pdf and the B Claims Processing Enterprise Architecture which can be found at the following URL: http://www.cms.gov/Medicare/Medicare-Contracting/Medicare-Administrative-Contractors/Downloads/A-B-Enterprise-Claims-Processing-Architecture.pdf
C.1.4.3 Jurisdiction-Specific Requirements The delegation of authority to the RRB requires the inclusion of the following provision from IOM Pub. 100-4, Chapter 12, §20.7 titled Comparability of Payment Provision of Delegation of Authority by CMS to the RRB.
The delegation of authority, under which the RRB administers the SMI Benefits Program for qualified railroad retirement beneficiaries, requires that: The RRB shall take such action as may be necessary to assure that payments made for services by the SMAC Contractor or intermediaries it selects will conform as closely as possible to the payment made for comparable services in the same locality by the A/B MAC acting for CMS.
The purpose of this comparability of payment is to reduce to the extent possible disparities between the payments made by the MAC or Contractor under the RRB delegation and the payments made by CMS’s A/B MACs for services or items furnished by the same physicians, including provider-based physicians, or suppliers. For all services paid for under the physician fee schedule, contractors under the RRB delegation pay based on the same fee schedule amount used by the A/B MACs.
C.1.4.4 Reserved
C.2 APPLICABLE DOCUMENTS
The following statutes, regulations, manuals, and documents apply to this contract.
C.2.1 Statutes The Contractor must comply with all applicable laws and regulations. The major statute governing the Medicare program is Title XVIII of the Social Security Act (Public Law 74-271), as amended. The Act and major amendments to the Act are outlined below (note: the list is not all inclusive). The identified amendments include legislation that significantly changed the Medicare program, are being implemented, or significantly affect the scope of work. Congress may pass new legislation at any time, and the CMS must act to implement such legislation as timely and accurately as possible. The Contractor must also comply with the RRA and the RUIA as well as all applicable regulations. 45 U.S.C. § 231 et seq.; 45 U.S.C. § 351 et seq.; 20 C.F.R. Parts 200-399.
C.2.1.1 Social Security Act (Public Law 74-271) The Act was enacted on August 14, 1935, with subsequent amendments. 45 U.S.C. § 401 et seq. The Act consists of 21 titles, several of which have been repealed. The HI and SMI programs are authorized by Title XVIII of the Act. The vast bulk of traditional Medicare’s FFS program authorizing law is codified in Title XVIII of the S Act, Parts A, B and E (Part C is primarily devoted to private Medicare plans, and Part D governs the Medicare prescription drug benefit). Other Medicare-related authorizing statutes may be found in Titles II and XI of the Act; other governing provisions are in the Internal Revenue Code, and other statutes.
To the extent that there is no conflicting Medicare requirement, the administration of the traditional Medicare FFS program is also governed by numerous statutes pertaining to the general administration of federal programs. The following are among the general statutory authorities with broad implications for the traditional Medicare FFS program and the MAC contract:
a) Rehabilitation Act of 1998 (including Section 508, Accessibility Standards)
b) Acquisition statues (Competition in Contracting Act, etc.)
c) Federal Information Security (IS) Management Act of 2014 (FISMA);
d) Government Performance and Results Act (GPRA) and GPRA Modernization Act;
e) Personnel and civil rights law (Drug-Free Workplace Act, Americans with Disability Act and amendments)
f) Privacy and information technology (IT) requirements (Privacy Act of 1974, IT Management Reform Act of 1996).
g) Financial management and internal controls (e.g., the Federal Managers’ Financial Integrity Act of 1982 , the Chief Financial Officers (CFOs)’ Act of 1990, etc.)
C.2.1.2 Medicare Prescription Drug, Improvement, and Modernization Act (MMA) (Public Law 108-173) On December 8, 2003, the President signed the MMA into law. This statute made the most sweeping changes in the structure of the Medicare program since its inception in 1966. The significant changes made by this statute include the following:
a) Establishment of a temporary Medicare prescription drug discount card program.
b) Establishment of a permanent Medicare prescription drug program.
c) Renaming of the Medicare+Choice to MA and provision of significant new incentives to facilitate the participation of private plans in Medicare.
d) Provision of certain preventative benefits under both traditional Medicare and MA.
e) Implementation of many changes in coverage and payment policy within traditional Medicare.
f) Implementation of many administrative and regulatory reforms within traditional Medicare.
g) Under Section 911 of the MMA, the restructuring of the acquisition statutes that govern traditional Medicare, commonly known as MCR. See C.1.3 above.
h) Under Section 912 of the MMA, requirements for MAC IS programs and independent evaluations thereof.
i) Under Section 921 of the MMA, provision requiring toll-free lines for provider inquiries and an expansion of provider education.
The work under this contract shall be affected by many of these provisions; however, the primary authority governing the terms and conditions of this contract is Section 911.
C.2.1.3 The Health Insurance Portability and Accountability Act of 1996 (Public Law 104-191) The Health Insurance Portability and Accountability Act (HIPAA) was enacted on August 21, 1996. Title II, Subtitle F, of HIPAA gives the DHHS the authority to mandate the use of standards for the electronic exchange of health care data; to specify what medical and administrative code sets should be used within those standards; to require the use of national identification systems for health care patients, providers, payers (or plans), and employers (or sponsors); and to specify the types of measures required to protect the security and privacy of personally identifiable health care information.
C.2.1.4 Administrative Simplification Compliance Act of 2002 (Public Law 107-105) The Administrative Simplification Compliance Act requires that providers of healthcare submit their claims to Medicare electronically, with limited exceptions, to qualify for payment.
C.2.1.5 The Tax Equity and Fiscal Responsibility Act of 1982 (Public Law 97-248) The Tax Equity and Fiscal Responsibility Act of 1982 made Medicare the secondary payer for certain employees and dependents.
C.2.1.6 Benefits Improvements and Protection Act of 2000 (Public Law 106-554) Section 521 of the Benefits Improvements and Protection Act of 2000 (BIPA) changed the Medicare appeals process to create a uniform procedure for handling all Medicare appeals (Parts A and B). BIPA also specified new time frames for filing appeals and specified time frames for filing appeals and rendering decisions.
C.2.1.7 Executive Order 13410 To the extent applicable and practical, the RRB SMAC shall follow Executive Order (EO) 13410: Promoting Quality and Efficient Health Care in Federal Government Administered or Sponsored Health Care Programs. This EO promotes the efficient delivery of quality health care through the use of health IT, transparency regarding health care quality and price, and incentives to promote the widespread adoption of health IT and quality of care. To support this mission, the RRB SMAC shall use recognized health information interoperability standards at the time of this contract, in all relevant IT systems supported, in whole or in part, through this contract.
This includes existing standards from the Health IT Standards Panel (HITSP) that have been recognized by the Secretary of HHS. Specific information regarding the HITSP standards can be found at www.hitsp.org.
C.2.2 Regulations The Contractor must comply with all applicable federal regulations, including but not limited to, all Medicare regulations. Generally, Medicare regulations are located in Title 42 and 45 of the Code of Federal Regulations (CFR).
C.2.3 Medicare Manuals Medicare manuals (e.g., Internet-only manuals—IOMs) are CMS program instructions, day-to-day operating instructions, policies, and procedures that are based on statutes and regulations, guidelines, models, and directives. CMS program components, providers, Contractors, and state survey agencies use Medicare manuals to administer CMS programs. As CMS paper-based manuals are updated, the updated materials are published in the IOMs and eliminated from the paper-based manuals. As noted at C.1, in the event of any conflict, this SOW shall have precedence over the IOM’s. Further, in the event of any conflict, the IOMs shall have precedence over the paper-based manuals. The CMS will continue this phase-out/phase-in process until all manual instructions are in the IOMs. The IOMs and paper-based manuals can be found at https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/index .
Citations in this SOW are generally to an IOM Publication (e.g. IOM Pub. XX). Paper-based manual citations are used only where necessary (indicated as CMS Pub. XX). The Contractor shall promptly notify the RRB through the COR or other appropriate staff and request confirmation of the instruction before taking any action if the Contractor believes that any case-specific CMS instruction even if directly issued by CMS or any of its subcontractors, any IOM or Paper-Based Manual instruction contradicts or conflicts with any other Medicare policy requirement. For the purposes of this notification requirement, a “Medicare policy requirement” includes any requirement in law, regulation, a CMS ruling, a national coverage determination, or another CMS manual instruction; moreover, within the boundaries this SMAC contract, the term “Medicare policy requirement” also includes a policy article or coverage determination established by the Contractor.
C.3 KEY DEFINITIONS
Several attachments to the solicitation package including this SOW and the SOW appendix, located in RFP attachment J.01.B, contain definitions critical to understanding this SOW and the solicitation package. Appendix A is an alphabetical listing of key definitions and Appendix B is a glossary of acronyms used throughout the SOW and the RFP package. These appendices are not intended to be an all-inclusive list of definitions for terms used throughout the SOW. Additional definitions pertinent to this solicitation package and SOW are available on https://www.cms.gov/apps/glossary/
C.4 OBJECTIVES
This acquisition supports the mission of the RRB, which includes assuring health care security for our beneficiaries. Both CMS’s and RRB’s strategic goals and objectives emphasize the themes of accountability, stewardship and a renewed focus on the customer. This has resulted in a commitment to RRB beneficiaries as the ultimate focus of all RRB activities, expenditures, and policies. To ensure that RRB remains a responsive, dynamic and relevant government agency that serves its beneficiaries, the RRB and CMS are committed to monitoring and evaluating the effectiveness of its programs.
Consistent with the GPRA principles, RRB (in coordination with CMS) has developed and/or set forth performance objectives for the Contractor including those in the areas of: customer service, operational excellence, innovation and technology, and financial management. In this SOW, the RRB, in coordination with CMS, has identified meaningful, outcome-oriented performance standards and measures that speak to the fundamental program purposes of the Medicare program and to CMS’s and RRB’s roles as a steward of taxpayer dollars.
C.4.1 Customer Service Customer service activities support the business relationship between FFS Medicare providers/suppliers and the RRB Medicare beneficiary program. Quality services to both groups increase the overall level of customer service and satisfaction. In support of this objective, the Contractor shall:
a) Maintain effective provider education that achieves accurate billing with prompt and correct provider payment;
b) Respond to RRB Medicare beneficiary electronic, telephone and written inquiries promptly, clearly, and accurately.
c) Respond to provider electronic, telephone and written inquiries promptly, clearly, and accurately.
d) Maintain a high level of beneficiary service and satisfaction by good communication and relationships with beneficiaries.
e) Maintain a high level of provider service and satisfaction by good communication and relationships with providers.
f) Maintain effective provider education that achieves accurate billing with prompt and correct payment.
g) Provide an overall environment in which providers understand the FFS Medicare program.
C.4.2 Operational Excellence Operational Excellence addresses the ability of employees, the quality of information systems, and the effects of organizational alignment in supporting the accomplishment of organizational goals. In support of achieving operational excellence, the Contractor shall do the following: (this list is not all-inclusive)
a) Promote corporate integrity and establish internal controls and an effective compliance program to achieve contractual goals and objectives.
b) Work collaboratively with RRB, CMS, providers, and other CMS contractors to foster integration of Medicare operations.
C.4.3 Innovation and Technology Innovation and Technology addresses internal business results that lead to financial success and satisfied customers. In support of Innovation and Technology, the Contractor shall do the following: (this list is not all-inclusive)
a) Foster efficiencies in the administration of the RRB Part B Medicare program to promote best value for the Government.
b) Develop and continually refine business processes to foster excellence and quality in the administration of the RRB Part B Medicare program.
c) Use innovation and creative solutions to improve the nationwide RRB program operation.
C.4.4 Financial Management Improving financial management, accountability, and responsible stewardship is a key initiative in the DHHS Strategic Plan and has been a long-term focus in achieving RRB’s and CMS’s mission. Under the Medicare Integrity Program , the RRB is focused on paying the right amount to legitimate providers for covered, reasonable and necessary services. Financial management also addresses efforts to promote cost efficiency and the ability to deliver maximum value to the customer. In support of financial management, the Contractor shall do the following:
a) Promote the fiscal integrity of the Medicare FFS program and be an accountable steward of public funds.
b) Pay Part B claims and process overpayments timely, accurately, and reliably.
C.5 FUNCTIONAL REQUIREMENTS
The Contractor shall perform all RRB SMAC functions specified in this SOW and outlined in the IOMs. For purposes of this contract, any IOM instructions/references to “FI” or “Intermediaries” are not applicable to this SOW. When differences or conflicts occur, this SOW shall take precedence over the IOMs unless otherwise specified by the CO or COR. The Contractor shall contact the CO and the COR if budgetary concerns occur because of this conflict.
C.5.1 Workload Implementation Requirements The Contractor shall carry out the orderly transfer of all Medicare data, records, and operations from the outgoing contractor in accordance with the Jurisdiction Implementation Project Plan.
During the implementation period, the term “transition” will be applied to activities that are being performed by more than just the incoming Contractor; i.e., others involved in the project such as the outgoing contractor, data center, etc. The term “implementation” is used for those activities normally associated with just the incoming Contractor. However, in general usage, the term “transition” often will be applied to the incoming Contractor’s implementation activities.
A workload implementation is defined as the entire scope of contractor activities associated with moving RRB Medicare functions from the outgoing Contractor.
A workload implementation is successful when the transfer of RRB Medicare data, records, and operational activities from the outgoing Contractor to the incoming (RRB SMAC) Contractor is accomplished so that:
a) There is minimal disruption to beneficiaries;
b) There is minimal disruption to providers;
c) There is no disruption of claims processing and Medicare operations;
d) The implementation is completed within the required time period as stated in the Implementation Project Plan;
e) Actual costs represent effective and efficient use of resources; and
f) All parties with an interest in the implementation (whether direct or indirect) are kept informed of the implementation’s status and progress.
The Contractor shall establish and maintain through the course of the implementation an experienced implementation management team.
C.5.1.1 Implementation Project Plan The Contractor shall develop, execute, and maintain a Jurisdiction Implementation Project Plan consistent with the Contractor’s proposed Jurisdiction Implementation Project Plan, submitted in its final proposal, and report its status. The Jurisdiction Implementation Project Plan shall include a detailed description of all activities required to transfer all RRB Medicare operations from the current contractor.
The contractor shall submit the Implementation Project Plan to the RRB immediately upon contract award. The contractor shall provide the RRB a revised Implementation Project Plan within 30 calendar days of contract award to reflect any changes in the Plan due to modification of the schedule or tasks.
The Contractor shall submit bi-weekly (every other week) updates to the…
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