Amendment_0001_-_J.9-Questions-Answers.doc

J.9 – Questions and Answers (QAs) Template

Questions and Answers – 75FCMC18R0004 *Please use the below required format. Also, make sure to add ‘CMS Answer’ below each question.

REQUEST FOR PROPOSAL QUESTIONS (RFP):

Question # 1

Section/ Page Number: Section B.2, Page 9

Question: How will monthly payments to the successful contractor be made under the resulting contract? Will the contractor be paid one-twelfth of the total annual firm fixed price each month of the contract or will the payment be based on the actual quantities (units) tasked each month for CLINs/SLINs AB through AG? For example, for accuracy reviews if the actual number of claims for a particular month are only 800 claims, will the payment be based on just this quantity?

CMS Answer: Accuracy Reviews, New Issue Quality Assurance Reviews, Travel, and Administrative Tasks (1, 2, 7, 8, 9, 10, and 12) will be paid on a bi weekly basis. Disputes, new issue proposal review, and support services will be paid on a monthly basis.

Question # 2

Section/ Page Number: Section B – Supplies or Services and Prices / Costs

Question: Can CMS confirm the quantity being identified in the pricing table for each task? Can the assumption be made that these units should be used in calculating overall LOE and price?

CMS Answer: CMS can confirm Task 3 (Accuracy Reviews) are fixed, tasks 4-6 is dependent based on need.

Question # 3 Section/ Page Number: H.1.c Significant Potential Conflict of Interest, page 29

Question: Does CMS believe that it is possible to mitigate COI of a proposed teaming partner (subcontractor) who is also a subcontractor to a RAC? When considering mitigation, to what degree does it matter what services the potential teaming partner is providing to the RAC?

CMS Answer: CMS does not believe that it is possible to mitigate COI of a proposed teaming partner (subcontractor) who is also a subcontractor to a RAC.

Question #4 Section/Page Number: K.11 FAR 52.219-1 SMALL BUSINESS PROGRAM REPRESENTATIONS (OCT 2014) (b), page 76

Question: The NAICS code specified for this solicitation is 524298. The incumbent contract is under NAICS code 541611 and the sources sought notice classified this work under NAICS code 541990. What is the rationale for the change(s) in NAICS code classification when no material change has been made in the scope and nature of the work?

CMS Answer: CMS has reviewed the NAICS code further and finds NAICS 524298 to be the most appropriate for the work being performed under this contract.

Question #5 Section/ Page Number: L.11, Tab D-Factor 4, Page 93

Question: Is the current contractor reviewing 30% of all claims for quality assurance purposes, or is this a new requirement for this RFP?

CMS Answer: This is a new requirement.

Question #6 Section/ Page Number: RFP, L.12, page 97 of 102

Question: Regarding Tab H, the Responsibility Questionnaire, Is it only the prime who must fill out this form, or must any proposed subcontractors do so as well?

CMS Answer: Yes, Attachment J.8 shall be completed by the prime and any proposed subcontractors. The solicitation has been updated.

Question #7 Section/ Page Number: Tab G – Factor 7: Past Performance, page 95 of 102

Question: To decrease the wasted white space in the table and make descriptions and relevance section easier to read (Please see sample below), may the information in the table be reformatted to take two rows for each contract with the items requiring paragraphs below the items requiring only data points?

Value Period of Performance Relevant (Y/N)

Description of Services/Supplies

Lorem ipsum dolor sit amet, consectetuer adipiscing elit, sed diam nonummy nibh euismod tincidunt ut laoreet dolore magna aliquam erat volutpat. Ut wisi enim ad minim veniam, quis nostrud exerci tation ullamcorper suscipit

Relevance

Lorem ipsum dolor sit amet, consectetuer adipiscing elit, sed diam nonummy nibh euismod tincidunt ut laoreet dolore magna aliquam erat volutpat. Ut wisi enim ad minim veniam, quis nostrud exerci tation ullamcorper suscipit

Additional Information

N/A

CMS Answer: This should be formatted according to the RFP.

Question #8 Section/ Page Number: RFP, L.12, page 97 of 102

Question: The RFP instructions for the Business Volume state the following:

Offerors shall submit an organization structure chart that depicts its current internal structure and the relationships between the parent company and any subsidiaries and/or affiliates. This structure should also include Business Units, Divisions, etc. A separate organization structure chart should be provided for each proposed significant subcontractor (as defined in Section L.11).

Should the separate organization structure chart for our subcontractor also depict its current internal structure and the relationships between the parent company and any of its subsidiaries and/or affiliates, or are you looking instead for an organizational chart that shows the relationships/reporting structure between the subcontractor and the prime?

CMS Answer: For each proposed subcontractor, CMS wants the current internal structure and the relationships between the parent company and any of its subsidiaries and/or affiliates, AND the relationships/reporting structure between the subcontractor and the prime for this solicitation. The solicitation has been updated to reflect this language.

Question #9 Section/ Page Number: Section L.11, Tab E-Factor 5, Page 94

Question: This section states that the contractor must outline an approach to obtain an Authority to Operate (ATO) within 60 days of contract award, while Task 12 on page 22 of the SOW states that the contractor must begin the process of obtaining an ATO within 60 days. Which time frame is correct?

CMS Answer: The contractor should obtain their ATO within the first 60 days.

Question #10 Section/ Page Number: Section L.14 – Proposal Assumptions, Page 99

Question: This section details an assumption that the contractor will need access to the Common Working File (CWF). What is meant by term “access”? Does it mean the ability to download information or to just perform one-for-one lookups?

CMS Answer: Access would be to look up claim information.

Question #11 Section/ Page Number: Section L.14 – Proposal Assumptions, Page 99

Question: This section details an assumption that the contractor will need a valid CMS ID to access the RAC Data Warehouse (RACDW). Do the contractor personnel identified for access need to be U.S. citizens or can they just have the right to work (green card).

CMS Answer: All applicants must be able to work in the U.S.

During the Data Warehouse application process, all applicants are vetted through the system (CMS Database) before obtaining access. They first must obtain the CMS user ID via EUA. EUA will determine if the SSN is valid or not.

MISCELLANEOUS:

Question #12 Section/ Page Number: Exhibit 1 Cost Proposal

Question: On the tabs for each period of performance, there is no separate row under Task 11 Travel to enter non-labor travel costs (mileage, per diem, etc.). Should non-labor travel costs be included in the “Subtotal ODCS” row, or should a row be added?

CMS Answer: Exhibit 1 – Cost Proposal Spreadsheet has been updated to include a spreadsheet for the breakdown of travel for each period. Once the travel is broken out in the travel spreadsheet, the total travel for each period may be provided under task 11 under spreadsheets Base Period, OY1, OY2, OY3 and OY4.

Question #13 Section/ Page Number: General

Question: The attachments jump from J.1 to J.4. Was this intentional or are there missing attachments (J.2 and J.3)? In the Table of Contents for the RFP, these attachments are listed as “reserved.” Does this mean the government will provide these attachments later?

CMS Answer: Once award is made, the required wage determinations will be included under J.2 and the Contractor’s organizational Conflict of Interest (Incorporated by reference) under J.3 for the awardee.

Question #14

Question: Would CMS Confirm that this solicitation is for RVC for all RAC regions?

CMS Answer: This solicitation is for RAC Regions 1-5.

Question #15

Question: Will claims denied by the RACs be subject to RVC review if they are still going through the regular appeals process (if the RAC decision is appealed) or will the appeals process be complete prior to the RVC review? If an appeal is in process and the RVC reverses full/part of a RAC denial decision and the RVC submits its findings to CMS, and the ultimate final decision (after disputes are resolved) is to reverse the RAC’s denial, will CMS engage the appropriate level of appeal and inform them of the decision? If so, would the RVC be required to participate in that outreach to the MAC, QIC, ALJ, etc.?

CMS Answer:

a. Will claims denied by the RACs be subject to RVC review if they are still going through the regular appeals process (if the RAC decision is appealed) or will the appeals process be complete prior to the RVC review?

a. Yes.

b. If an appeal is in process and the RVC reverses full/part of a RAC denial decision and the RVC submits its findings to CMS, and the ultimate final decision (after disputes are resolved) is to reverse the RAC’s denial, will CMS engage the appropriate level of appeal and inform them of the decision?

a. No.

c. If so, would the RVC be required to participate in that outreach to the MAC, QIC, ALJ, etc.?

a. No.

Question #16

Question: Can CMS advise on the expected breakdown of automated RAC reviews versus complex RAC reviews in a typical monthly sample of 1000 claims?

CMS Answer: No, because the sample is dependent on what the RAC’s review in a given month.

Question #17

Question: Are there any requirements for an alternate recovery site solution?

CMS Answer: This should be a part of the contingency plan.

Alternate storage sites:

· Be separated from the primary storage site(s)

· Identify potential accessibility problems to the alternate storage site(s) and outline explicit mitigation actions

· Ensure information security measures equivalent to those of the primary storage site(s) are provided

Question #18

Question: Are there any requirements regarding business continuity or disaster recovery plans and exercises?

CMS Answer: This should be a part of the contingency plan.

· The system backup strategy must document processes to:

· Support the information system recovery

· Store backup copies of the operating system and other critical information system software, as well as copies of the information system inventory, in a physically separate facility or in a fire-rated container not co-located with the operational system

· Meet business continuity needs, including the identified RTO and RPO

Question #19

Question: Are there any requirements regarding business continuity recovery timeframes; Recovery Point Objective, Recovery Time Objective, or Maximum Allowable Outage?

CMS Answer:

· The system backup strategy must document processes to:

· Support the information system recovery

· Store backup copies of the operating system and other critical information system software, as well as copies of the information system inventory, in a physically separate facility or in a fire-rated container not co-located with the operational system

· Meet business continuity needs, including the identified RTO and RPO

Question #20 Section/ Page Number: Exhibit 1 Cost Proposal

Question: The Government’s spreadsheets are not accompanied by written instructions nor do the cells contain links or formulas. Will the Government provide instructions, links and/or formulas?

CMS Answer: A contractor should use and apply their own formulas.

Question #21

Question: Is Row 22 – Total Cost the sum of all costs before fee/profit? Is Row 24 the sum of costs before fee/profit plus the fee/profit and is this the Total Firm Fixed Price? If so, why are only columns B-K (Tasks 1 – 3) merged on row 24 in each of the 5 supporting schedules? Since it appears that the intent of the spreadsheets is for the total cost plus fee/profit to be the same as the Total Firm Fixed Price, then should the amount in cell AU24 be the value carried forward to Column E of the Summary by Cost Element schedule? Is this how the Government intended for the spreadsheets to be used?

CMS Answer: Exhibit 1 – Cost Proposal Spreadsheet has been updated to reflect the correct layout.

Question #22

Question: Is the value in Column D of the Summary by Cost Element the unit price simply calculated by dividing the amount in Column E by the quantity in Column C?

CMS Answer: Yes.

Question #23

Question: What does the Government want in Column F of the Summary by Cost Element as the Period of Performance in the solicitation is “TBD”? Can the Government please provide the Period of Performance as prices can vary by the actual time periods?

CMS Answer: The Period of performance does not need to be filled in by the contractor. This contract is estimated to be awarded during calendar year 2018.

STATEMENT OF WORK (SOW) QUESTIONS:

Question #24 Section/ Page Number: General Question

Question: Currently, do all of the RACs submit information/data to the RAC Validation Contractor in a standardized format? If not, how is the information/data submitted for each of the 5 RACs?

CMS Answer: Each RAC is allowed to provide their own format, however CMS requires them to provide the following:

· Detail of the claim selected for audit (sample claim) and anchor/reference claims, including, but not limited to:

· Claim number (e.g., Internal Control Number (ICN) or Document Control Number (DCN)); Beneficiary name, Health Insurance Claim Number (HICN), Date of Birth (DOB), and Date of Death (DOD); Applicable provider numbers (National Provider Identifier (NPI)) and/or Employee Identification Numbers (EIN) ; Diagnosis code(s); Type of Bill (TOB), Date of Service (DOS), Type of Service (TOS), and Place of Service (POS); All items/services billed including all modifiers appended, number of units, and charges; Diagnosis Related Groups (DRG) and billed diagnosis/procedure codes; Condition/occurrence codes; Discharge status code

· If applicable, submissions from the RAC case management system are acceptable; however may need to be supplemented depending on information captured in the system and requirements of NI under audit.

· Medical record, for all complex reviews, as well as any document submitted as part of a discussion period

· Correspondence

· Additional Documentation Request (ADR) Letters, Review Results Letters, Requests for Discussion, Results of Discussion Period, etc.

· Additional Information about the claim being reviewed

· Any information related to closure or cancellation of a claim review

· A short explanation when associated findings by the MAC change the final outcome of the RAC determination (if applicable)

· Notification of any claims in the sample being under internal discussion, at the time of RVC review The RAC shall send all requested medical records to the RVC by CD/DVD in Portable Document Format (PDF). This CD/DVD will be password protected.

Question #25 Section/ Page Number: System Requirements and Data Accessibility / 5

Question: Please confirm that CMS will provide access to the Medicare Data Communications Network (MDCN) and Multiprotocol Label Switching (MPLS) upon contract award.

CMS Answer: The CMS Wide Area Network (WAN) consists of CMSNet (formerly MDCN) and the CMS Extranet. The WAN interconnects all CMS locations and CMS business partner/contractor locations and provides a vast network of communication and data exchange. CMS has a contract vehicle in place for establishing CMSNet network connectivity between all CMS data centers.

Question #26

Section/ Page Number: Section III. Requirements, i. General Requirements, 1. Initial Meeting/ page 5

Question: What program application (tool) should be used to submit the formal project plan?

CMS Answer: CMS standard is Microsoft Word 2010.

Question #27

Section/ Page Number: I. Purpose, Page 3

Question: The opening paragraph speaks to the RVC ensuring the RACs “are not unnecessarily denying Medicare claims that were properly paid.” This statement suggests that the RVC reviews will focus on RAC overpayment determinations. However, throughout the SOW there are broader indications that suggest all improper payments (overpayments and underpayments) will be reviewed. Can CMS clarify the scope of RVC reviews…RAC overpayment decisions (i.e., RAC denials) or both overpayments and underpayments?

CMS Answer: The RVC can review overpayments, underpayments, and no findings if requested by CMS.

Question #28 Section/ Page Number: ii. System Requirements and Data Accessibility, page 5

Question:

The SOW states, “If this SOW requires the Contractor to (1) process, (2) store, (3) facilitate transport, or (4) host/maintain Federal information…” a.

Which of these items, if any, is the RVC required to perform?

b.

What Federal information is the RVC required to process, store, transport, or host/maintain?

CMS Answer:

a. Which of these items, if any, is the RVC required to perform?

a. The RVC is required to process, store, facilitate transport, and host/maintain federal information.

b. What Federal information is the RVC required to process, store, transport, or host/maintain?

a. Part A/B Medicare claims

Question #29

Section/ Page Number: iii. Task 3: Accuracy Reviews, page 6

Question:

a. In what format will CMS provide the (up to) 1,000 claims data?

b. How will CMS transmit the claims data on a monthly basis?

c. Is there a requirement for the RVC to be able to programmatically receive and store the claims data?

CMS Answer:

a. In what format will CMS provide the (up to) 1,000 claims data?

a. RAC will provide password protected data through CD/DVD to the RVC.

b. How will CMS transmit the claims data on a monthly basis?

a. Excel via email.

c. Is there a requirement for the RVC to be able to programmatically receive and store the claims data?

a. The RVC shall maintain a case file for all claim samples, including documentation review. The case file may be electronic, paper or a combination of both. The RVC shall not destroy any supporting documentation relating to the identification or recovery process. The RVC shall store these cases in such a way that they can be accessed immediately upon request. The RVC shall retain the findings for each claim indefinitely. CMS will provide additional direction for case files upon the RVC contracts completion. All case files shall meet the requirements as set by Office of Management and Budget (OMB) Circular A-130, which can be found at (http://www.whitehouse.gov/omb/circulars/a130/a130trans4.html).

Question #30 Section/ Page Number: xii. Task 12: Ensuring Compliance with CMS Security Requirements, page 21

Question:

a.

What is the name of the FISMA system in CFACTS which supports the current RVC?

b.

When does its ATO expire?

3.

What is its Impact Level rating (Low, Moderate or High)?

CMS Answer:

a. What is the name of the FISMA system in CFACTS which supports the current RVC?

a. PRI Review Systems

b. When does its ATO expire?

a. The ATO will expire at the completion of their contract.

c. What is its Impact Level rating (Low, Moderate or High)?

a. Moderate

Question #31

Section/ Page Number: I. Purpose, Page 3

Question: Are “no finding claims” those claims for which the RAC has not found any indication of an improper payment?

Question #32

Section/ Page Number: III.i. General Requirements, Page 4

Question: The QA section (Page 9) suggests this, but please confirm that the RVC will be given or will have access to all medical documentation used by the RAC and all coverage and payment policies in effect as of the date-of-service/discharge on the claim.

CMS Answer: Yes, they will receive all medical documentation used by the RAC for accuracy reviews. However, it is the RVC’s responsibility to ensure they have access to coverage and payment policies in effect during the date of service/discharge on the claim.

Question #33

Section/ Page Number: IV.ii. Task 2: RVC Operations Manual, Page 6

Question: As written, it appears the RVC Operations Manual would reflect standard operations and processes primarily focused on medical reviews, reporting procedures, “and other processes and business rules.” Can CMS elaborate on what it might expect the Operations Manual to discuss regarding the Special Studies required by the SOW, communications with CMS and other contractors, etc.?

CMS Answer:

· Special Studies- process flow for receiving special study notifications/request and how the contractor will perform quality assurance on special studies

· Communications- how all RVC determinations will be provided to CMS, how communications between the RVC and RACs will be coordinated, possible RAC inquiries about RVC determinations

Question #34

Section/ Page Number: IV.iii. Task 3: Accuracy Reviews, Page 6

Question: If the sample of claims includes both overpayments and underpayments, is there an estimate of how many of the 1,000 sample claims will fall into each category?

CMS Answer: No, it is dependent on what the RAC reviews.

Question #35

Question: Per the earlier question, will the RVC receive any sample claims that are going through the appeals process?

Question #36

Question: This section states that “at CMS’ discretion the RVC may be requested to recode and re-price claims,” please provide an estimate for the number of claims the RVC repriced in the last two contract years.

CMS Answer: CMS cannot provide the number of claims the RVC has repriced because the RVC does not participate in repricing of claims. However, at CMS’ discretion the RVC may be requested to provide a recommendation to recode and re-price claims if the RAC denied based on the incorrect code or payment amount.

Question #37 Section/ Page Number: IV.iii. Task 3: Accuracy Reviews, Page 7

Question: There is a requirement that the “RVC will be responsible for purchasing all pricers and groupers needed for the reviews.” May we assume this includes fee schedules as well? Many Pricers and fee schedules are available free of charge through the CMS website (i.e., many PC Pricers and fee schedules). Assuming the free products would be acceptable, can CMS provide the names of vendors which would sell the other needed products (e.g., OPPS Pricer, Groupers, certain fee schedules, etc.)? Will CMS provide access to pricing information for DMEPOS claims paid through competitive bidding?

CMS Answer: CMS cannot provide names of vendors or pricing information paid through competitive bidding because it is the RVC’s responsibility to ensure they gain access or have pricers or fee schedules needed to perform reviews.

Question #38

Section/ Page Number: IV.iii. Task 3: Accuracy Reviews, Pages 8-10

Question: This section talks about the monthly Accuracy Report, per RAC, and a separate monthly report for each RAC region that addresses New Issue and Policy Recommendations. What vehicle should be used to report upon issues and findings that cross more than one RAC region and are indicative of possible systemic issues (e.g., across the nation)? Would this be reported in every RAC’s monthly report and/or as part of the Monthly Progress Report (see question below)?

CMS Answer: The contractor would address regions claim specific issues on the month accuracy report. If there is a specific issue noticed with the review concept, the contractor is to address it in the New Issue and Policy Recommendations Report. If there are any major findings identified across the nation, this can be identified in the monthly progress report.

Question #39

Section/ Page Number: IV.iii. Task 3: Accuracy Reviews, Page 11

Question: What does the acronym “RRL” stand for?

CMS Answer: Review Results Letter

Question #40

Section/ Page Number: IV.v Task 5: Special Studies, Page 13

Question: Can CMS provide additional detail/examples about the goals and objectives of the Special Studies, over/above “to inform CMS management of specific topics or areas of interest”? Are there examples of such possible special studies?

CMS Answer: Special studies are conducted if CMS requires a more in depth look at how a particular issue is being reviewed. Special studies can include any type of RAC review (automated/complex) including reviews that resulted in no findings.

Question #41

Section/ Page Number: IV.v Task 5: Special Studies, #1, Page 14

Question: The first and second paragraphs have redundant requirements related to a 508-compliant Special Study Report that is due by the 30th calendar day following receipt by the RVC of the Special Study package. Is this simply redundant language or is more than one report required?

CMS Answer: Special study reports are similar in nature to accuracy reports, however, special study reports are completed at the request of CMS and once requested is due in 30 calendar days. Unlike accuracy reviews, the contractor shall review up to 500 claims per year for special studies at CMS’ request. The contractor may review none, half, or all, but it is based on CMS discretion.

Question #42

Section/ Page Number: IV.v Task 5: Special Studies, #2, Page 14

Question: This section essentially states that the Special Study Report(s) is due the same day as the Accuracy Report. This common due date suggests that the Special Study package(s) will always be delivered to the RVC on the same day as the RVC receives the monthly accuracy sample. Is this a correct assumption?

CMS Answer: The special study is something that is completed at the request of CMS and once requested is due in 30 calendar days. The contractor shall review up to 500 claims per year for special studies at CMS’ request.

Question #43

Section/ Page Number: IV.vi. Task 6: New Issue Review/2. New Issue Quality Assurance Review, Page 17

Question: Please provide an estimate of the number of NI packages submitted to the RVC for the last two contract years.

CMS Answer: This is a new task.

Question #44

Section/ Page Number: IV.vi. Task 6: New Issue Review/3. New Issue Support Services, Page 18

Question: Does the DRAO Review Team prefer educational activities be conducted via webinar? How many educational activities are anticipated per contract year?

CMS Answer: Yes, we prefer webinar. The contractor has up to 10 hrs per year to utilize. This task can be utilized based on CMS’ need and discretion.

Question #45

Section/ Page Number: IV.vii Task 7: Contractor Quality Assurance, Page 18

Question: The QA plan is to include a minimum review of 30% of all claims reviewed (accuracy reviews and special studies). Does this mean a stratified review reflective of 30% of the 12,000 annual accuracy review claims plus 30% of 500 annual Special Study claims, or 30% of the aggregated (12,500 per year) claims, regardless of which category they fall in?

CMS Answer: 30% of all claims reviewed.

Question #46

Section/ Page Number: IV.viii Task 8: Monthly Progress Reports, Pages 18-19

Question: Are these reports per RAC region or an aggregate for all RAC regions? If an aggregate, is this where cross-RAC issues should be addressed/discussed (per earlier question)?

CMS Answer: These monthly reports are across all RAC regions. This is where cross-RAC issues can addressed/discussed.

Question #47 Section/ Page Number: V. Administrative and Miscellaneous Topics, Page 22

Question: Are there any requirements for the physical location of the RVC’s operations?

CMS Answer: There are no requirements for the physical location of the RVC’s operations as long as all the SOW requirements are met. If the contractor is requesting to work offshore, prior permission is required.

Question #48 Section/ Page Number: V.vii RVC Transitions, Page 24

Question: There are very few specific requirements related to transitioning in/out for the new and incumbent contractors. Are there requirements for the outgoing contractor that relate to incomplete workloads, processes, etc.? Will all pending or incomplete work be simply turned over to the new RVC? If there are disagreements among the incoming/outgoing contractors, will CMS step in to resolve the situation to ensure a smooth transition? For what will the outgoing contractor be held accountable?

CMS Answer:

a. Are there requirements for the outgoing contractor that relate to incomplete workloads, processes, etc.?

a. There will not be any incomplete work. There will be no expected communications amongst the outgoing contractor and the new contractor.

b. Will all pending or incomplete work be simply turned over to the new RVC?

a. There will not be any incomplete work. There will be no expected communications amongst the outgoing contractor and the new contractor.

c. If there are disagreements among the incoming/outgoing contractors, will CMS step in to resolve the situation to ensure a smooth transition?

a. There will not be any incomplete work. There will be no expected communications amongst the outgoing contractor and the new contractor.

d. For what will the outgoing contractor be held accountable?

a. Nothing because there will not be any incomplete work. There will be no expected communications amongst the outgoing contractor and the new contractor.

Question #49 Section/ Page Number: VI. Personnel Requirements, Page 24

Question: Must Key Personnel, Essential Personnel, and Additional Personnel all be full-time positions or may some be part-time? If some positions may be part-time, which ones?

CMS Answer: Chief Compliance Officer, System Analyst, Application Developer, System Administrator, and 508 Compliance Officer may be part-time positions

Question #50 Section/ Page Number: Appendix A: Schedule of Deliverables, Page 31

Question: Per Page 6, the RVC Operations Manual (Task 2) deliverable that is due 30 days after contract award is a “draft.” The deliverable in the Appendix A schedule does not make reference to a draft nor does the schedule reflect the due date for the final RVC Operations Manual. Does this need to be clarified in the Appendix?

CMS Answer: This has been clarified in the appendix. The draft manual is due close of business 30 days after contract award, if no comments are received from CMS within 30 days after draft submission, the RVC shall submit the final document within 10 calendar days..

Question # 51 Section/ Page Number: SOW, Section VI.iii, Additional Personnel, Page 28

Question: Can these resources be part time or shared so long as they are always available to the RVC when needed?

CMS Answer: The Project Coordinator role should not be part-time or shared, however, the Chief Compliance Officer, System Analyst, Application Developer, System Administrator, and 508 Compliance Officer can be part-time or shared.

Question #52 Section/ Page Number: SOW, Section III, ii, pg 5

Question: Would CMS EFT provide sufficient data exchange with CMS rather than MDCN?

CMS Answer: Contractors that expect to transmit Section 111 files with more than 24,000 records in one file submission on a regular basis may wish to submit via Connect: Direct, formerly known as Network Data Mover (NDM), via a connection to the CMS Extranet Network and CMS’ private CMSNet network.

Question #53 Section/ Page Number: Task 2: RVC Operations Manual / 6

Question: Will the Government share the RVC Operations Manual and other reports/documentation/templates from the previous contract upon award?

CMS Answer: CMS will provide guidance; however, we will not turn over documents or templates from the previous contract.

Question #54 Section/ Page Number: Task 3: Accuracy Reviews / 6

Question: Please provide more detail for how the randomly selected claims and associated medical records will be provided by the RACs to the RVC.

CMS Answer: CMS will provide monthly samples to the RACs, the RVC will be notified of the samples chosen and the RACs will provide the RVC and CMS with case files (medical records) within 7 business days so accuracy reviews can be initiated.

Question #55

Question: Is there a standardized format for the claims data that will be provided by the RACs or is each RAC providing their own format? Will the medical records be provided in digital form? If so, what format?

CMS Answer: The RAC shall send all requested medical records in by CD/DVD in Portable Document Format (PDF). Image file formats (ex. JPG, TIF, GIF, and PNG) will not be accepted.

Each RAC is allowed to provide their own format, however CMS requires them to provide the following:

· Detail of the claim selected for audit (sample claim) and anchor/reference claims, including, but not limited to:

· Claim number (e.g., Internal Control Number (ICN) or Document Control Number (DCN)); Beneficiary name, Health Insurance Claim Number (HICN), Date of Birth (DOB), and Date of Death (DOD); Applicable provider numbers (National Provider Identifier (NPI)) and/or Employee Identification Numbers (EIN) ; Diagnosis code(s); Type of Bill (TOB), Date of Service (DOS), Type of Service (TOS), and Place of Service (POS); All items/services billed including all modifiers appended, number of units, and charges; Diagnosis Related Groups (DRG) and billed diagnosis/procedure codes; Condition/occurrence codes; Discharge status code

· If applicable, submissions from the RAC case management system are acceptable; however may need to be supplemented depending on information captured in the system and requirements of NI under audit.

· Medical record, for all complex reviews, as well as any document submitted as part of a discussion period

· Correspondence

· Additional Documentation Request (ADR) Letters, Review Results Letters, Requests for Discussion, Results of Discussion Period, etc.

· Additional Information about the claim being reviewed

· Any information related to closure or cancellation of a claim review

· A short explanation when associated findings by the MAC change the final outcome of the RAC determination (if applicable)

· Notification of any claims in the sample being under internal discussion, at the time of RVC review

Question #56 Section/ Page Number: Task 3: Accuracy Reviews / 8

Question: Are the RACs currently authorized to conduct prepayment reviews?

CMS Answer: No. Claims for these types of reviews may be assigned at CMS discretion, but will only be assigned when CMS has the authority to use Recovery Auditors to conduct prepayment review.

Question #57 Section/ Page Number: Task 3: Accuracy Reviews / 12

Question: Approximately how many disputes are conducted per year? How many times has CMS disagreed with the RVC decision, thus triggering a corrective action plan on average per year?

CMS Answer:

· Disputes for FY 2016- 20 disputes

· Disputes for FY 2017- 10 disputes The rate of overturn is dependent upon the contractor performance so it would not be relevant to the incoming contractor.

Question #58 Section/ Page Number: Task 3: Accuracy Reviews / 13

Question: Can the government share a couple of special studies examples that have been conducted in the last contract?

CMS Answer:

· Post Acute Care Transfers Overpayment

· Medically Unlikely Edits

· Excisional Debridement

Question #59

Question: Out of the 12,000 claims that need to be reviewed per year, what is the typical distribution of automated, semi-automated, and complex reviews that have been performed by the RACs? Will there be claims included that did not undergo a review by the RACs?

CMS Answer: We no longer do semi-automated reviews. All claims undergo review by RACs. We are unable to predict the distribution.

Question #60

Question: What is the desired protocol for interacting with the RACs? Are there direct lines of communication with the RACs or do we need to go through the COR/GTL to ask questions?

CMS Answer: The contractor should go through their COR.

Question #61 Section/ Page Number: RVC Transitions / 23

Question: How long will the transition period be from the incumbent contractor?

CMS Answer: The transition refers to contract closeout that will occur between previous contractor and CMS. It does not relate to the incoming contractor. There will not be any incomplete work. There will be no expected communications amongst the outgoing contractor and the new contractor.

Question #62 Section/ Page Number: RVC Transitions / 23

Question: Will the incumbent contractor transition systems that have been developed to support the RVC contract?

CMS Answer: Contractor systems will not transition. The incoming contractor will have to use their own internal system.

Question #63

Question: How soon after contract award will the new contractor start receiving claims for review?

CMS Answer: The contractor has to establish an ATO before they can receive claims from the RAC. The contractor should obtain their ATO within the first 60 days.

Question #64

Question: Under what task should the transition from the incumbent contractor be budgeted for?

CMS Answer: The new contractor is not expected to perform any transition tasks.

Question #65 Section/ Page Number: Essential Personnel/ 27

Question: The SOW says we are to maintain and operation an ATO, what ATO boundaries are the contractor responsible for supporting? For the contractor internal systems, will a dual ATO be required?

CMS Answer: The ATO is based on each system meeting/exceeding the minimum federal security and privacy requirements through an SCA and a Security Assessment and Authorization (SA&A)—formerly, Certification and Accreditation (C&A)--the methodology by which an organization establishes and demonstrates a sound information security posture for its system.

Question #66 Section/ Page number: Task 3: Accuracy Reviews / 11; Additional Personnel/ 29

Question: Is the contractor responsible for supporting and maintaining the RVC data warehouse and application tool?

CMS Answer: The RAC Data Warehouse (RACDW) is maintained by another contractor. The RVC will only be responsible for uploading each claim reviewed into the RACDW.

Question #67 Section/Page Number: Task 3: Accuracy Reviews/ 11; Additional Personnel / 29

Question: Is the incumbent PRI review system located at a CMS data center or the incumbent site? Will the PRI review system be transitioned to the current contractor? If not, will CMS provide PRI System Business Process Models?

CMS Answer: Contractor systems will not transition. The incoming contractor will have to use their own internal system.

Question #68 Section/ Page Number: SOW, Section IV, Task 3: Accuracy Reviews, Page 6

Question: The previous SOW required the current contractor to review 400 randomly selected claims as part of the contract. Is the current contractor now reviewing on average 1,000 claims per month, or is this a new requirement for this statement of work? If this is not a new requirement, when did the current contractor starting reviewing the increased volume of claims?

Question #69 Section/ Page Number: SOW, Section IV, Task 3: Accuracy Reviews, Page 7

Question: How does the RVC receive from the RACs the Medical Records associated with each RAC Claim? How are the medical records transmitted to the RVC?

CMS Answer: The RAC shall send all requested medical records in by CD/DVD in Portable Document Format (PDF). Image file formats (ex. JPG, TIF, GIF, and PNG) will not be accepted.

Each RAC is allowed to provide their own format, however CMS requires them to provide the following:

· Detail of the claim selected for audit (sample claim) and anchor/reference claims, including, but not limited to:

· Claim number (e.g., Internal Control Number (ICN) or Document Control Number (DCN)); Beneficiary name, Health Insurance Claim Number (HICN), Date of Birth (DOB), and Date of Death (DOD); Applicable provider numbers (National Provider Identifier (NPI)) and/or Employee Identification Numbers (EIN) ; Diagnosis code(s); Type of Bill (TOB), Date of Service (DOS), Type of Service (TOS), and Place of Service (POS); All items/services billed including all modifiers appended, number of units, and charges; Diagnosis Related Groups (DRG) and billed diagnosis/procedure codes; Condition/occurrence codes; Discharge status code

· If applicable, submissions from the RAC case management system are acceptable; however may need to be supplemented depending on information captured in the system and requirements of NI under audit.

· Medical record, for all complex reviews, as well as any document submitted as part of a discussion period

· Correspondence

· Additional Documentation Request (ADR) Letters, Review Results Letters, Requests for Discussion, Results of Discussion Period, etc.

· Additional Information about the claim being reviewed

· Any information related to closure or cancellation of a claim review

· A short explanation when associated findings by the MAC change the final outcome of the RAC determination (if applicable)

Notification of any claims in the sample being under internal discussion, at the time of RVC review

Question #70

Question: When the RAC forwards to the RVC the claim information for each claim in the sample, will the RAC include a list of the records it is sending for the RVC to confirm receipt?

CMS Answer: No. The RAC does not forward the RVC anything. CMS will relay information to the RVC.

Question #71

Question: What is the estimate of the volume of claims that will need to be recoded/repriced?

CMS Answer: This is dependent on what the RAC’s review and the cost of the claim. Also, it depends on if the RVC disagrees with the improper payment amount.

Question #72

Question: Is the required repricing of claims based on allowed amounts?

CMS Answer: The RVC does not participate in repricing of claims, however, at CMS’ discretion the RVC may recommend on the various RVC reports repricing or recoding of a claim if the RAC denied based on the incorrect code or payment amount.

Question #73 Section/ Page Number: SOW, Section IV, Task 6: New Issue Review, Page 14

Question: The New Issue Reviews task contains new requirements under this SOW. Is the current contractor now performing the volumes of 360 proposal, 360 approved and 10 support? If this is not a new requirement, when did the current contractor begin performing the new volumes?

Question #74

Question: How many New Issue Reviews were generated under the current contractor?

CMS Answer: The RVC does not generate New Issues however with the NEW RAC contracts there are currently 73 approved New Issue concepts.

Question #75

Question: Will the New Issue Reviews that the current contractor completed be available to the follow-on contractor?

CMS Answer: The approved new issues would come from CMS.

Question #76

Question: How many New Issues Reviews did the current contractor perform that were not approved?

How many New Issue Reviews were approved?

CMS Answer: None. This is a new requirement.

Question #77

Question: How many New Issue Reviews will require a medical record review?

CMS Answer:

· Approved Complex New Issue Concepts during Accuracy Studies.

Question #78 Section/ Page Number: SOW, Section IV, Task 7: Contractor Quality Assurance, Page 18

Question: The previous statement of work had a 10% Quality Assurance (QA) requirement. Is the current contractor performing 30% QA reviews, or is this a new requirement for this SOW?

CMS Answer: This a new requirement.

Question #79 Section/ Page Number: SOW Section IV, Task 10: Meetings and Conference Calls, Page 20

Question: Please provide estimates of the time for each call and the number of participants.

CMS Answer: Approximately 1 hr per call and anywhere from 5 to 25 attendees.

Question #80 Section/ Page Number: SOW Section IV, Task 12: Ensuring Compliance with CMS Security Requirements, Page 21

Question: Is the contractor required to select, hire, and contract with an approved ST&E contractor to comply with the requirement to independently evaluate and test its systems security program?

CMS Answer: No; CMS has contracted with independent systems evaluators.

Question #81 Section/ Page Number: SOW Section IV, Task 12: Ensuring Compliance with CMS Security Requirements, Page 21

Question: Is the cost to perform the initial ST&E and subsequent annual audits to be billed directly to the government, or is the cost to be borne by the customer.

CMS Answer: CMS takes care of both.

Question #82 Section/ Page Number: SOW Section IV, Task 12: Ensuring Compliance with CMS Security Requirements, Page 22

Question: Is the Authority to Operate (ATO) required before the RVC can commence Accuracy Reviews?

Question #83 Section/ Page Number: SOW Section IV, Task 12: Ensuring Compliance with CMS Security Requirements, Page 22

Question: If the contractor has submitted the package to CMS to obtain an ATO within 60 days of award, can the RVC begin to perform Accuracy Reviews without the ATO?

CMS Answer: No, an ATO has to be obtained first.

Question #84 Section/ Page Number: SOW Section 6, Personnel Requirements, Program Manager, Page 25

Question: What is the rationale for CMS preferring a degree in nursing for this position as this is not a current requirement under similar medical review contracts?

CMS Answer: This is a medical review contract and it is a benefit to have a nurse to be a point of contact and the program manager for the validation contractor.

Question #85 Section/ Page Number: SOW Section 6, Personnel Requirements, Key Personnel, Medical Review Manager, Page 26

Question: Is the quality assurance experience a requirement for the Medical Review Manager, clinical quality assurance experience or quality assurance of medical reviews experience?

CMS Answer: Quality assurance of medical reviews experience. This has been clarified in the SOW.

Question #86 Section/ Page Number: SOW Section 6, Personnel Requirements, Key Personnel, Medical Review Manager, Page 27

Question: This section states that the backup for the Medical Review Manager will be required to have the ability to answer questions to the same degree as the Contractor Medical Director (CMD). Should that say Medical Review Manager or is CMD correct?

CMS Answer: Medical Review Manager. This has been clarified in the SOW.

Question #87 Section/ Page Number: SOW Section 6, Personnel Requirements, Essential Personnel, System Security Officer (SSO), Page 27

Question: This section states that the SSO will have a minimum of a bachelor’s degree and should be credentialed in systems security (e.g. Certified Information Systems Security Professional [CISSP]). The CMS BPSSM, Section 2.2 states that the principal SSO position for each contractor should be…credentialed in systems security (e.g., Certified Information Systems Security Professional [CISSP]), but has no requirement for having a bachelor’s degree. Would a CISSP with 10 years of experience be acceptable in lieu of the required bachelor’s degree?

CMS Answer:

The principal SSO position for each contractor should be full-time and fully qualified—preferably credentialed in systems security (e.g., Certified Information Systems Security Professional [CISSP]). Having an individual with appropriate education and experience to execute security administration duties will help reinforce that security must be a cultural norm that guides daily activities, and not a set of compliance directives. A qualified SSO who is available to direct security operations full-time provides the foundation for the security culture and awareness of the organization.

The principal SSO should earn a minimum of 40 hours in continuing professional education credits each year from a recognized national information systems security organization. The educational sessions conducted at the CMS Security Controls Oversight and Update Training (CSCOUT) can be used toward fulfilling the continuing professional education credits. The qualifying sessions and associated credit hours will be noted on the CSCOUT agenda.

Question #88 Section/ Page Number: SOW, Section 6, Personnel Requirements, Essential Personnel, RVC Medical Reviewers

Question: This section states that RVC Medical Reviews shall possess a minimum of an associate’s degree in nursing from an accredited institution. If an RVC Reviewer is a licensed RN with 30 years of directly relevant experience, would that be permissible in lieu of an associate’s degree? Would a currently licensed nurse reviewer with a nursing certificate from a 3-year hospital based Federal program, a BA with an emphasis in psychology/sociology, and a certificate in healthcare management be permissible in lieu of an associate’s degree in nursing?

CMS Answer: These personnel must meet SOW requirements.