Amendment_2_-_Attachment_J.1_PEO_IDIQ_SOW.pdf

Centers for Medicare & Medicaid Services

Provider Enrollment and Oversight

Indefinite-Delivery Indefinite-Quantity Contract

Statement of Work (SOW)

75FCMC18R0014 Attachment J.1 IDIQ SOW Amendment 0002

Vision Statement

1 Background

1.1 Assumptions

1.2 Acronyms

1.3 Scope

2 General Requirements

2.1 Non-Personal Services

2.2 Business Relations

2.3 Contract Administration and Management

2.3.1 Contract Management

2.3.2 Contract Administration

2.3.3 Personnel Administration

2.4 Subcontract Management

2.5 Contractor Personnel, Disciplines, and Specialties

2.6 Location and Hours of Work

2.7 Travel / Temporary Duty (TDY)

3 Performance Requirements

3.1 Fingerprint Services

3.2 Site Verification Services

3.3 Provider Enrollment Appeals and Rebuttals

3.4 National Provider Enrollment Services

3.5 Provider Enrollment State Oversight Services

3.6 Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) License Verification Services

3.7 Provider Enrollment Accreditation Services

3.8 Enrollment Waiver for Moratoria Services

3.9 Provider Enrollment Education and Outreach Services

3.10 Provider Enrollment Data Analysis Services

3.11 Provider Enrollment Systems Testing Services

3.12 Provider Enrollment Requirements Services

3.13 Adverse Legal Action Services

4 Special Requirements

4.1 Transition

4.2 Government Furnished Materials

4.2.1 Government Furnished Information

4.2.2 Contractor Access to CMS Facilities and Systems

4.2.3 Government Furnished Equipment

4.2.4 Government Furnished Facilities

4.3 Quality

4.3.1 Quality Control

4.3.1.1 Quality Assurance Surveillance Plan (QASP)

4.4 Section 508 Accessibility of Electronic and Information Technology

5 Deliverables

Centers for Medicare & Medicaid Services (CMS) Provider Enrollment and Oversight (PEO) Indefinite Delivery Indefinite Quantity Contract (IDIQ) Statement of Work (SOW)

Vision Statement

The purpose of this IDIQ is to obtain a Provider Enrollment and Oversight Contract (hereinafter referred to as "Contractor" or "PEO-IDIQ") to detect, prevent, and proactively deter fraud, waste and abuse in the Medicare and Medicaid programs. PEO-IDIQ contractors shall perform their responsibilities under the direction of CMS.

1 Background

CMS currently relies on a network of contractors to carryout program integrity and provider enrollment and screening tasks in the Medicare and Medicaid programs. The strategies for these contracts are based on the specific legislative authorities that enacted the individual programs. The enrollment and screening process is constantly evolving through new regulations and authorities to address Medicare and Medicaid program vulnerabilities and prevent fraud, waste and abuse. In order to implement and operationalize these changes quickly and efficiently, CMS requires a contracting vehicle that is agile with means of adapting to the swift demands and ever-changing enrollment and screening landscape.

Medicare

Medicare is the federal health insurance program for people who are 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant, also referred to as ESRD). Nearly all Medicare beneficiaries access the majority of their insurance benefits through one of two health care delivery systems traditional Medicare, also known as Medicare Fee-for-Service (FFS), or Medicare Advantage (MA). Provider enrollment is the gateway to the Medicare program and is the key to preventing ineligible providers and suppliers from entering the program. CMS directly administers Medicare and oversees the provider enrollment and screening process for providers and suppliers participating in the Medicare FFS program. CMS uses provider enrollment information in a variety of ways, such as provider enrollment, claims payment and fraud prevention.

Currently the Medicare FFS provider and supplier universe consists of 2,068,273 enrollments and there are approximately 1.5 million enrollment transactions that are processed annually.

Medicaid

Medicaid is a joint federal-state funded health insurance program that is the primary source of medical assistance for millions of low-income, disabled, and elderly Americans. The federal government establishes minimum requirements for the program and states design, implement, administer, and oversee their own Medicaid programs. In general, states pay for the health benefits provided, and the federal government, in turn, matches qualified state expenditures based on the Federal medical assistance percentage (FMAP), which can be no lower than 50 percent.

All states participate in the Medicaid program and, as a requirement for receipt of federal matching payments, must cover individuals who meet certain minimum financial eligibility standards.

Additionally, the states must cover certain medical services, such as physician, hospital and nursing home care, and are provided the flexibility to offer a large number of optional benefits to beneficiaries.

States also have the option to expand their Medicaid programs to cover additional beneficiaries who have income above the minimum financial threshold, up to statutory limits on income levels. State governments have a great deal of programmatic flexibility within which to tailor their Medicaid programs to their unique political, budgetary, and economic environments.

1.1 Assumptions

The PEO IDIQ contract establishes assumptions that are applicable to all task orders and all Contractors:

o CMS may elect to perform all or part of a task or issue a Task Order for the Contractor to conduct provider enrollment and screening services as required, by the scope and complexity of the program/project.

o Task Order Statement of Work (SOWs) will be tailored as appropriate to the individual projects.

o The Contractor shall verify the quality of work products through formalized internal reviews and audits.

o The Contractor shall communicate the plan and schedule these quality measures at project startup. Subsequently, the Contractor shall report monthly to CMS (or as specified by the CMS Contracting Officer (CO) results of reviews and audits, including risks, issues, and plans to mitigate and/or rectify contributing factors.

o The Contractor shall not use any proprietary processes, hardware, software, etc. unless approved by CMS.

o All products created under this PEO IDIQ are the sole property of CMS.

o The Contractor shall perform all PEO-IDIQ and task order requirements in accordance with

Title XVIII of the Social Security Act ("the Act), Title 42 of the Code of Federal Regulations (CFR), the Statement of Work (SOW), the Program Integrity Manual (PIM) chapter 15, the Medicaid Provider Enrollment Compendium (MPEC), and all other applicable CMS directives.

1.2 Acronyms

Business Function Lead (BFL) - Technical lead for individual task orders. Works closely with the COR to monitor the day to day operations of the Contractor and assist in the evaluation of the Contractors overall success in meeting the PEO-IDIQ requirements. A BFL does not have the authority to issue technical direction to the contractor. All communication and interaction with the CMS BFL and any supporting contractor related to any task area should not be construed as a change, or intent to change, the scope of work under contract.

Contracting Officer (CO) - Individual who is duly appointed and designated with specific authority to enter into, administer, and terminate contracts and to make related determinations and findings on behalf of the U.S. Government.

Contracting Officer Representative (COR) - Individual, including a Contracting Officers Technical Representative (COTR), designated and authorized in writing by the Contracting Officer to perform specific technical or administrative functions related to monitoring a contract.

Medicare Administrative Contractors (MACs) - responsible for receipt and processing of Medicare Fee for Service (FFS) provider/supplier enrollment applications.

Provider Enrollment and Oversight Indefinite Delivery, Indefinite Quantity Contracts (PEO-IDIQ)

- a contract that provides for an indefinite quantity of supplies or services during a fixed period of time.

The enrollment and screening process is constantly evolving through new regulations and authorities to address Medicare and Medicaid program vulnerabilities and prevent fraud, waste and abuse. In order to implement and operationalize these changes quickly and efficiently, CPI requires a contracting vehicle that is agile with means of adapting to the swift demands and ever-changing enrollment and screening landscape.

Provider Enrollment Chain and Ownership System (PECOS) - the official CMS system of record for Medicare Fee-for-Service provider enrollment data. The PECOS application has an administrative interface used by CMS and the MACs enrollment specialist personnel, and an Internet-based provider interface used by applicants. The PECOS Provider Interface is available 24 hours a day, six days a week with scheduled downtime on Sundays.

Subject Matter Expert (SME) - a person who has expertise in a particular subject matter. All communication and interaction with the CMS SME and any supporting contractor related to any task area should not be construed as a change, or intent to change, the scope of work under contract.

1.3 Scope

The PEO-IDIQ, acting 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 SOW.

2 General Requirements

This section describes the general requirements for the PEO-IDIQ.

2.1 Non-Personal Services

The Government shall neither supervise Contractor employees nor control the method by which the Contractor performs the required tasks. Under no circumstances shall the Government assign tasks to, or prepare work schedules for, individual Contractor employees. It shall be the responsibility of the Contractor to manage its employees and to guard against any actions that are of the nature of personal services, or give the perception of personal services. If the Contractor believes that any actions constitute, or are perceived to constitute personal services, it shall be the contractor's responsibility to notify their CO immediately.

2.2 Business Relations

The Contractor shall successfully integrate and coordinate all activities needed to execute the PEO-IDIQ requirements. The Contractor shall manage the timeliness, completeness, and quality of all issues identified. The Contractor shall provide corrective action plans, proposal submittals, timely identification of issues, and effective management of subcontractors. The Contractor shall seek to ensure that Contractor personnel are displaying customer satisfaction, professionalism and ethical behavior.

2.3 Contract Administration and Management

The following subsections specify requirements for contract, management, and personnel administration.

2.3.1 Contract Management

The Contractor shall establish clear organizational lines of authority and responsibility to ensure effective management of the resources assigned to the requirement. The Contractor must maintain continuity between the support operations at CMS headquarters in Baltimore, Maryland and the Contractor's corporate offices. The Contractor shall complete final project reporting, perform inventory and close out activities, and complete certificate of data destruction.

2.3.2 Contract Administration

The Contractor shall establish processes and assign appropriate resources to effectively administer the PEO-IDIQ requirements. The Contractor shall respond to Government requests for contractual actions in a timely fashion.

Within ten 10 calendar days of task order issuance, or as otherwise specified, the Contractor will need to complete the following for each task order:

o Assign work effort and maintain proper and accurate time keeping records of personnel assigned to work on the PEO-IDIQ requirements.

o Hold a project Kick-Off Meeting by conference call or in-person in Baltimore, Maryland at which the Contractor will present its team and its understanding of the tasks to be performed. The meeting will kick-off technical performance under an awarded performance period and serve to establish initial coordination of activities and meeting schedules with the COR.

o Develop and present a walk-through of the Contractor’s project management plan (PMP) and schedule (MS Project schedule) for the COR and other supporting team members within five ten (105) calendar days after award of each performance period for purposes of achieving a common understanding of the sequence of activities, expected inputs, processes and procedures, and outputs. This may take place as part of the Kick-Off Meeting.

o Provide any required PMP updates and schedule revisions within ten 10 calendar days of receipt of technical direction comments from the COR.

o Within 10 calendar days of award, provide a personnel management and training plan to include:

Procedures and processes used to select and train Contractor personnel for this project.

Evidence of Contractor personnel suitability determination prior to assignment for this project.

Systems and/or reports that will be utilized to document training activities and the annual training plan (training schedule).

Develop and maintain training materials within twenty 20 calendar days, subject to approval by CMS

Develop and maintain standard operating procedures (SOPs) for implementation of each of the service areas defined in the SOW; which may take the form of a manual of operations, procedures memos, office instructions, guidance directives, or business process diagrams and supporting documentation with defined performance/service delivery targets.

Beginning no later than thirty (30) calendar days after award of any performance period, participate in monthly project meetings (by telephone or in person as defined by CMS) with the COR, Business Function Lead (BFL), other CMS representatives and Contractors as necessary to discuss the current status of the project, key challenges, accomplishments, and upcoming activities.

Arrange meetings (by phone or in person as defined by CMS) with the COR, BFL, other CMS representatives and CMS contractors, as necessary to coordinate the proper workflow of activities to accomplish the performance objectives of the SOW.

Develop and have available electronic meeting minutes for all regularly scheduled, or ad-hoc meetings. Meeting minutes should specify action items, outstanding issues, follow-up activities, decisions, etc. and be distributed to attendees and any CMS-approved grouping.

Deliver monthly technical status reports that include progress of activities/task areas performed under the SOW and a summary of the authorized project budget and current and cumulative Contractor expenditures.

Provide an organization chart with names of all lead personnel (including applicable Subcontractors) supporting each SOW task or project activity, and updates to reflect changes in personnel assignments. This may be provided as part of the PMP.

Define and maintain a set of metrics that provide an indication of project performance and status. The agreed upon metrics and performance measures may be defined as part of the PMP. Once defined, routine reporting against the agreed to metrics shall be presented in the monthly status report. Exact formats will be mutually agreed upon between the Contractor and the COR/BFL, and will be subject to change at CMS direction. Tracking reports may be delivered to CMS in a Microsoft excel spreadsheet format.

2.3.3 Personnel Administration

The Contractor shall provide the following management and support as required:

o The Contractor shall make necessary travel arrangements for employees.

o The Contractor shall provide necessary infrastructure to support contract tasks.

2.4 Subcontract Management

The Contractor shall be responsible for managing all subcontractors and shall be responsible and accountable for subcontractor performance on the PEO-IDIQ requirements. The prime contractor will manage work distribution to ensure that no Organizational Conflict of Interest (OCI) exists. Contractors may add subcontractors to their team after notification to the Contracting Officer (CO) or the Contracting Officer Representative (COR).

2.5 Contractor Personnel, Disciplines, and Specialties

The Contractor shall propose appropriate personnel at the task order level who shall be designated as "Key Personnel.” Key Personnel will be identified in each individual task order. At a minimum the Contractor shall dedicate a Project Manager whose roles and responsibilities shall be defined by the Contractor’s technical approach and management plan outlined in each task order. The key personnel specified in any task order will be considered to be essential to work performance. At least 30 days prior to the contractor voluntarily diverting any of the specified individuals to other programs or contracts the Contractor shall notify the Contracting Officer and shall submit a justification for the diversion or replacement and a request to replace the individual. The request must identify the proposed replacement and provide an explanation of how the replacement's skills, experience, and credentials meet or exceed the requirements of the contract. If the employee of the contractor is terminated for cause or separates from the contractor voluntarily with less than thirty days’ notice, the Contractor shall provide the maximum notice practicable under the circumstances. The Contractor shall not divert, replace, or announce any such change to key personnel without the written consent of the Contracting Officer. The contract will be modified to add or delete key personnel as necessary to reflect the agreement of the parties.

2.6 Location and Hours of Work

The Contractor shall provide all necessary work locations for its personnel to support CMS to meet the PEO-IDIQ requirements.

2.7 Travel / Temporary Duty (TDY)

Travel to other government facilities or other contractor facilities may be required and will be specified in the task order SOW. All travel requirements (including plans, agenda, itinerary, or dates) shall be pre-approved by the government (subject to local policy procedures) unless otherwise stated in the Task Order.

Costs for travel shall be billed in accordance with the regulatory implementation of Public Law 99- 234 and FAR 31.205-46 Travel Costs (subject to local policy & procedures; may reference FAR), unless otherwise stated in the Task Order.

3 Performance Requirements

The following section specifies potential task orders to be established by CMS and the performance objectives and performance elements that the Contractors are required to meet for the PEO-IDIQ contract.

3.1 Fingerprint Services

3.1.1 Fingerprint Services’ Requirements

1. The Contractor shall perform provider enrollment fingerprint-based background checks for Medicare Parts A, B, C, DME and/or Medicaid.

2. The Contractor shall obtain fingerprint-based Criminal History Record Information (CHRI) from the FBI.

3. The Contractor shall pass-through the CHRI to the Authorized Recipient (CMS).

4. The Contractor shall receive the CHRI from CMS for processing.

5. The Contractor shall store and interpret the CHRI for CMS.

6. The Contractor shall provide customer support services to the provider community to assist them in completing their fingerprint requirements.

7. The Contractor shall deliver to CMS the contractors fitness recommendation indicating whether the CHRI contains enrollment violations or otherwise fails to meet requirements or guidelines established by CMS for enrollment of or to maintain enrollment of a Medicare provider or supplier.

8. The Contractor shall have an executed FBI-Channeler agreement that is kept current for the duration of the contract period and proof of the current agreement will be required prior to the exercise of any options.

9. The Contractor shall provide a physical data center site that meets all FBI site security considerations, CMS Acceptable Risk Standards (ARS) and CMS Technical Reference Architecture (TRA) requirements for Federal Information Systems Management Act (FISMA)-moderate level applications. FISMA requires federal agencies to implement a mandatory set of processes and system controls designed to ensure the confidentiality, integrity, and availability of system-related information. The processes and systems controls in each federal agency must follow established Federal Information Processing Standards, National Institute of Standards and Technology standards, and other legislative requirements pertaining to federal information systems, such as the Privacy Act of 1974. The data center must be FISMA certified.

10. The Contractor shall channel and store for CMS the fingerprint outcomes and identity information of individual applicants that are subject to a fingerprint-based background check to satisfy enrollment requirements. CMS will identify the providers required to submit fingerprints.

11. The Contractor shall provide data processing and storage capabilities that ensures the integrity and security of the fingerprint data, CHRI, and other case related data. These systems shall allow CMS to access this data as requested by CMS. The process is initiated by CMS sending notification of an individual who is required to be fingerprinted so the case management record can be established.

3.1.1.1 Fingerprint Services’ Performance Standards

a) Standard: Obtain and complete the review of FBI CHRI records upon notice from CMS.

b) Standard: Deliver to CMS complete fitness recommendations indicating whether the CHRI contains enrollment violations or otherwise fails to meet requirements or guidelines established by CMS for enrollment of or to maintain enrollment of Medicare provider or supplier.

c) Standard: Deliver proven commercial systems that can be adapted to service the requirements of

CMS users and continued ability to maintain the system during the life of the contract.

d) Standard: Provide fingerprint channeling customer support available by website and by call center (phone) support that is available to applicants at least 5 days a week, excluding federal holidays.

e) Standard: Safeguard records and data for the life of the contract and at end of the contract deliver the contractor-acquired data to CMS in a readable and usable format to CMS for its record retention purposes.

3.2 Site Verification Services

3.2.1 Site Verification Services’ Requirements

1. This contract will consist of a single Contractor or multiple Contractors that will perform all provider enrollment site visits nationwide for Medicare Parts A, B, C, DME and/or Medicaid.

2. The Contractor shall conduct site verification inspection services for providers/suppliers designated as limited, moderate and high risk in Medicare and located in states identified in the Task Order, include visiting provider locations , conducting internal site visits, taking photographs of the locations visited, and documenting their findings.

3. The Contractor shall have the capacity through existing networks, systems, processes, or partnerships to visit provider/supplier sites, whether urban or rural, at locations in all states identified in the Task Order.

4. The Contractor shall also have the capacity to provide nationwide site verification services for all 50 States and 6 territories if required by CMS.

5. The Contractor shall be able to perform site visits in specified timeframes (e.g., within 48 hrs. 7 days, 15 days, or 30 days) and submit reports to CMS within the timeframes specified by CMS.

6. The Contractor shall be able to collect site visit specific information based on CMS defined questionnaires.

7. The Contractor shall be able to collect the sites geographic coordinates and photos at the physical location via a smartphone or similar device (e.g., Blackberry, iPhone, Android) with GPS capabilities, including the ability to geotag photos, and provide a method of recording, storing and transmitting images back to CMS.

8. The Contractor shall report system to system acknowledgement of site visit data received from CMS in a weekly or daily file as directed by CMS.

9. The Contractor shall submit all site visit information and forms to CMS to be integrated into the CMS provider enrollment systems (PECOS).

10. The Contractor shall be equipped to perform physical observational or in depth site inspections to determine a provider/suppliers compliance with Medicare enrollment requirements, to include provider, staff and customer interviews as part of the site inspections.

11. The Contractor shall provide customer support to manage quality control of site visit records, to address and troubleshoot issues as they arise, and to provide routine progress or status reporting.

12. The Contractor shall provide bulk migration of all photos and documents at the end of the contract period as directed by CMS.

13. The Contractor shall provide training and oversight of all site verification inspectors throughout the life of the contract.

3.2.1.1 Site Verification Services’ Performance Standards

a) Standard: Perform physical site inspections nationwide, with capacity through existing networks, systems, processes, or partnerships to visit provider/supplier sites, whether urban or rural, at locations in all states identified in the Task Order.

b) Standard: Perform nationwide site verification services for all 50 States and 6 Territories if required by CMS.

c) Standard: Accurately identify the site locations as operational or non-operational.

d) Standard: Inspection form is accurate and complete.

e) Standard: Reports submitted to CMS within the timeframes specified by CMS schedule.

3.3 Provider Enrollment Appeals and Rebuttals

3.3.1 Provider Enrollment Appeals and Rebuttals’ Requirements

1. Must possess the legal training and skills to conduct a thorough legal analysis for corrective action plans (CAPs) and reconsideration requests regarding the individual facts and circumstances for each initial determination.

2. This review may include, but is not limited to provider enrollment denials, revocations, and effective date determinations.

3. A thorough legal analysis will include a factual summary that led to the initial determination, a review of all relevant documentation, and application of the relevant regulations and sub-regulatory guidance.

4. All decisions must adhere to commonly accepted grammar rules.

In addition to reviewing initial determinations, the contractor must be able to conduct a thorough legal analysis of provider enrollment deactivations resulting in the submission of a rebuttal.

Requirement Descriptions

Corrective Action Plan (CAP) – A CAP allows a provider or supplier an opportunity to demonstrate compliance by correcting the deficiencies (if possible) that led to denial of enrollment or revocation of billing privileges. A CAP may only be submitted in response to the denial of an enrollment application under 42 C.F.R. § 424.530 or a revocation of billing privileges for noncompliance under 42 C.F.R. § 424.535(a)(1).

Reconsideration Request – A reconsideration request allows the provider or supplier to demonstrate that there was an error in the initial determination at the time the initial determination was implemented.

Initial Determination – A decision made by CMS or its contractor regarding the Medicare enrollment of a provider or supplier, which includes, but is not limited to the denial of a Medicare enrollment application, the revocation of Medicare billing privileges, and the determination of an effective date of participation in the Medicare program. Appeal rights extend from initial determinations.

Denial – The denial of a provider or supplier’s Medicare enrollment application.

Revocation – The revocation of a provider or supplier’s Medicare billing privileges and any corresponding provider or supplier agreement.

Effective Date Determination – The determination of a provider or supplier’s effective date of participation in the Medicare program, specifically in relation to the provider or supplier’s ability to bill the Medicare program for services rendered.

Regulations – The Code of Federal Regulations (mainly Title 42).

Sub-Regulatory Guidance – Direction issued by CMS via the Medicare Program Integrity Manual

(MPIM).

Grammar Rules – Set of structural rules governing the composition of clauses, phrases, and words in the English language.

Deactivations – The provider or supplier’s Medicare billing privileges have been stopped, but can be restored upon the submission of updated information.

3.3.1.1 Appeals and Rebuttals Performance Standards

a). Provide appeal and rebuttal documentation to CMS in a timely manner.

b). Provide accurate justifications for provider denials and revocations c). Provide accurate on provider corrective action plans.

3.4 National Provider Enrollment Services

3.4.1 National Provider Enrollment Services’ Requirements

1. This contract will consist of a single contractor or multiple Contractors that perform all provider enrollment functions nationwide.

2. The Contractor shall process enrollment applications from providers/suppliers who are enrolling in Medicare Parts A, B, C, DME and/or Medicaid and any other future Medicare and/or Medicaid benefit types. At CMS discretion, these potential task orders may be awarded individually, combined or some combination thereof (i.e., Eastern and Western regions or all A/B and DME).

3. The Contractor shall manage the CMS Medicare and/or Medicaid provider enrollment process in accordance with CMS instructions.

4. The Contractor shall utilize the OMB approved Medicare and/or Medicaid enrollment applications or Internet-based PECOS enrollment applications to enroll providers/suppliers into the Medicare and/or Medicaid program or make changes existing provider/supplier enrollment information.

5. The Contractor shall use the government-furnished Provider Enrollment, Chain Ownership System (PECOS), and any other CMS systems, to establish an enrollment record within the Medicare and/or Medicaid program or change an existing Medicare and/or Medicaid enrollment previously established using PECOS.

6. The Contractor shall verify and screen the enrollment data contained on the enrollment applications.

7. The Contractor shall deny a provider/suppliers Medicare and/or Medicaid enrollment application if appropriate.

8. The Contractor shall revoke or terminate a provider/suppliers Medicare and/or Medicaid billing privileges if CMS or the contractor determines that a revocation or termination is appropriate.

9. The Contractor shall deactivate a provider/suppliers Medicare and/or Medicaid billing privileges if appropriate.

10. The Contractor shall evaluate appeals of Medicare and/or Medicaid denials and revocations/terminations to determine whether an appropriate action was taken.

11. The Contractor shall manage and resolve Medicare and/or Medicaid provider enrollment inquiries (calls, emails, and fax).

12. The Contractor shall train provider enrollment staff on the provider enrollment process.

13. The Contractor shall coordinate with other CMS contractors as directed by CMS.

3.4.1.1 National Provider Enrollment Services’ Performance Standards

a) Standard: Completes all enrollment actions within CMS specified timeframes.

b) Standard: Communicate early identification of enrollment system or application problems to

CMS.

c) Standard: Manage and resolve Medicare and/or Medicaid provider enrollment inquiries within CMS specified timeframes

3.5 Provider Enrollment State Oversight Services

3.5.1 Provider Enrollment State Oversight Services’ Requirements

1. The Contractor shall perform onsite assessments of the Medicaid State Agencies (SMAs) provider screening and enrollment activities and their compliance with the requirements in 42 CFR 455 Subpart E and the CMS Medicaid Provider Enrollment Compendium

(MPEC).

2. The Contractor shall review, assess, and document existing state policies, procedures, and business processes related to provider screening and enrollment.

3. The Contractor shall be familiar with the 42 CFR 455 Subpart E related Medicaid regulatory requirements and the CMS MPEC to gain understanding of CMS expectations for state compliance.

4. The Contractor shall conduct a risk assessment/gap analysis of the as-is state to document non-compliance with 42 CFR 455 Subpart E and CMS MPEC, vulnerabilities, and opportunities for improvement of provider screening and enrollment policies, procedures, and business processes.

5. The Contractor shall identify and document specific, actionable activities that the state can undertake to enhance or improve provider screening and enrollment policies, procedures, and business processes.

3.5.1.1 Provider Enrollment State Oversight Services’ Performance Standards

a) Standard: Completes all State oversight actions within specified timeframes.

b) Standard: Continued process improvement throughout life of contract.

c) Standard: Accurately identifies status of State assessment through final reports.

3.6 Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS)

License Verification Services

3.6.1 DMEPOS License Verification Services’ Requirements

1. The Contractor shall coordinate with all states and territories (hereinafter referred to as "state), on a quarterly basis, to obtain updates to their state licensure requirements for suppliers providing DMEPOS supplies and services.

2. The Contractor shall ensure that suppliers are maintaining an active license, as required, to remain in compliance with the competitive bidding requirements and the provider enrollment requirements throughout their enrollment.

3. The Contractor shall continuously monitor and maintain a complete licensure database that tracks changes in state licensure requirements and the suppliers who are no longer in compliance with these requirements.

4. The Contractor shall collaborate and coordinate delivery of suppliers not meeting state licensure requirements, to CMS or its designated contractor, for further assessment and action.

3.6.1.1 DMEPOS License Verification Services’ Performance Standards

a) Standard: Completes all license verification actions within specified timeframes. Reports are accurate with verifiable data.

b) Standard: Zero error rates per licensing cycle.

c) Standard: Addresses all errors and identifies corrective licensing actions.

3.7 Provider Enrollment Accreditation Services

3.7.1 Provider Enrollment Accreditation Services’ Requirements

1. The Contractor shall collaborate and establish a relationship with all the accreditation organizations (AO).

2. The Contractor shall perform verification and tracking of all product accreditation requirements and identify suppliers that are not meeting the accreditation requirements.

3. The Contractor shall collaborate and coordinate delivery of AO related reports and other information, to CMS or its designated contractor, for further assessment and action.

4. The Contractor shall manage AO and product related inquiries (calls, emails, and fax).

5. The Contractor shall hold regular status meetings with AOs and CMS.

6. The Contractor shall provide education regarding product accreditation requirements.

3.7.1.1 Provider Enrollment Accreditation Services’ Performance Standards

a) Standard: Completes all accreditation verification actions within specified timeframes. Reports are accurate with verifiable data.

b) Standard: Zero error rates per licensing cycle.

c) Standard: Addresses all errors and identifies corrective licensing actions.

3.8 Enrollment Waiver for Moratoria Services

3.8.1 Enrollment Waiver Moratoria Services’ Requirements

1. The Contractor shall assess the effectiveness of the implementation of the moratoria demonstration by analyzing CMS data.

2. The Contractor shall compile and run their own data to assess the demonstration program.

This data will serve as a supplemental review, alongside the review of CMS data, of the demonstrations ability to reduce fraud.

3. The Contractor shall analyze whether there was any provider movement beyond the moratoria areas, for the intent of circumventing the moratoria, using the data provided by CMS in conjunction with data compiled independently by the contractor.

4. The Contractor shall report findings to CMS within CMS specified timelines requirements.

5. The Contractor shall create a process to determine what constitutes a beneficiary access to care issue through scrutiny of CMS provided data, and any other pertinent data or resources.

6. The Contractor shall develop an ongoing process to monitor beneficiary access to care.

7. The Contractor shall analyze CMS current processes to determine whether an adequate screening of provider/suppliers is being conducted and advise CMS of any potential improvements to this process.

3.8.1.1 Enrollment Waiver for Moratoria Services’ Performance Standards

a) Standard: Moratoria reports are accurate and verifiable

b) Standard: Completes all demonstration activities within specified timeframes.

c) Standard: Communicate early identification of Moratoria issues to CMS.

3.9 Provider Enrollment Education and Outreach Services

3.9.1 Provider Enrollment Education and Outreach Services’ Requirements

1. The Contractor shall develop training materials to educate the Medicare Part A, Part B, Part C, DMEPOS and/or Medicaid provider/supplier community on current provider enrollment regulatory and sub-regulatory guidance.

2. The Contractor shall coordinate with CMS to develop training materials to educate the Medicare Part A, Part B, Part C, DMEPOS and/or Medicaid provider/supplier community on newly released provider enrollment regulatory and sub-regulatory guidance.

3. The Contractor shall develop training materials to educate the Medicare Part A, Part B, Part C, DMEPOS and/or Medicaid provider/supplier community on the usage of the Provider Enrollment Chain and Ownership System (PECOS).

4. The Contractor shall maintain an ongoing PECOS workshop and develop training materials to educate the Medicare Part A, Part B, Part C, DMEPOS and/or Medicaid provider/supplier community on PECOS enhancements.

5. The Contractor shall hold semi-annual, in-person Education & Outreach seminars for the provider/supplier community. A typical seminar should be able to accommodate 600 – 700 attendees and will last for 2 days. However, CMS reserves the right to have smaller or larger conferences during the life of the contract.

6. The Contractor shall hold regular teleconferences and webinars open to the provider/supplier community. Teleconferences and webinars should be available on request or as instructed by CMS. The number of virtual attendees could vary. Workshops should be available on request or as instructed by CMS.

7. The Contractor shall be available for provider enrollment education workshops by appointment both in-person and via teleconference or webinar.

8. The Contractor shall submit all training materials to CMS for approval prior to usage.

9. The Contractor shall obtain written approval from CMS prior to engagement with providers and their contact persons.

9.10. The contractor should have enrollment tutorials and training materials available on-demand. Live workshops should be available on request or as instructed by CMS.

3.9.1.1 Provider Enrollment Education and Outreach Services’ Performance Standards

a) Standard: All training materials will be developed on time and as specified by CMS.

b) Standard: Training materials are accurate and complete.

c) Standard: Maintain latest video and teleconferencing technologies and capabilities.

3.10 Provider Enrollment Data Analysis Services

3.10.1 Provider Enrollment Data Analysis Services’ Requirements

1. The Contractor shall access all necessary Medicare and Medicaid provider enrollment data, health care claims, administrative and partner data as made available by CMS and required by task leads to facilitate analytical requests of provider enrollment systems.

2. The Contractor shall routinely access all the required Medicare and Medicaid data sources in a timely manner, but also retain specific attributes of historical data to facilitate statistically valid analyses accounting for lag in the data.

3. The Contractor shall support Medicare and Medicaid data analytics needs for Medicare enrollment program operations such as program monitoring, policy support and program evaluation.

4. The Contractor shall develop the narrative and quantitative summaries presenting evaluation findings and other program metrics as requested by CMS.

5. The Contractor shall conduct any ad-hoc data analyses requested by CMS.

6. The Contractor shall provide customized reports, data files, and data visualizations in response to CMS and partner queries.

7. The Contractor shall develop an audit strategy delineating specific audit methods and criteria to examine data submitted for the Medicare enrollment program and ensure its compliance with program rule and other requirements.

8. The Contractor shall carry out all Medicare and Medicaid qualitative and quantitative analyses of primary and secondary data as requested by CMS.

9. The Contractor shall perform Medicare and Medicaid analyses deemed necessary to conduct enrollment systems data monitoring.

10. The Contractor shall collaborate frequently with government experts in the development, and iterative refinement, of analysis plans.

11. The Contractor shall have extensive working knowledge of Medicare and Medicaid enrollment data, healthcare claims and administrative data.

12. The Contractor shall have extensive knowledge of Medicare and Medicaid enrollment and payment policies and procedures to facilitate accurate analyses. Contractor will be expected to make recommendations, or respond to recommendations of federal experts, in the development and refinement of analysis plans.

3.10.1.1 Provider Enrollment Data Analysis Services Performance Standards

a) Standard: Weekly reporting of quantitative and qualitative analysis, on time and accurate.

b) Standard: Communicate early identification of analytical issues or problems to CMS.

3.11 Provider Enrollment Systems Testing Services

3.11.1 Provider Enrollment Systems Testing Services’ Requirements

1. The contractor shall perform detailed User Acceptance Testing for new and existing systems and system updates/changes defined by the current system contractor.

2. The contractor shall perform additional detailed Usability and Quality Assurance testing for new and existing systems and system updates/changes. The Contractor shall also provide ongoing support and consultation to ensure that the design, layout, and organization of the site are intuitive and user-friendly.

3. The Contractor shall provide personnel with expertise in usability of federal government Web sites and online applications. Personnel assigned to this task order must possess professional skills and extensive experience in the area of Web design and usability.

3.11.1.1 Provider Enrollment Systems Testing Services’ Performance Standards

Standard: Testing error rate must be no more than 1% per testing task.

a) Standard: Reports are accurate with verifiable data.

b) Standard: Address all errors and identifies corrective actions.

3.12 Provider Enrollment Requirements Services

3.12.1 Provider Enrollment Requirements Services’ Requirements

1. The Contractor shall perform extensive collaboration with CMS and stakeholders to gather and define program or system requirements.

2. Requirements must be measurable, testable, related to identified business needs or opportunities, and defined to a level of detail sufficient for system design.

3. Requirements shall capture the intent of requested changes, and stated requirements from users. Contractor shall also ensure that all requirements and deliverables accurately reflect the use of industry best practices.

4. The Contractor shall provide program management support which includes the management and oversight of all activities performed for new and existing provider enrollment systems and/or projects. The contractor shall identify a Program Manager (PM) who shall provide management, direction, administration, quality assurance, and leadership of the execution of the provider system and/or project.

3.12.1.1 Provider Enrollment Requirements Services’ Standards

a) Standard: Reports are accurate with verifiable data.

b) Standard: Communicates early identification of operational system problems.

c) Standard: Complete all enrollment requirement services actions within specified deadlines.

3.13 Adverse Legal Action Services

3.13.1 Adverse Legal Action Services’ Requirements

1. The Contractor shall develop internal processes to investigate and substantiate adverse legal actions as defined at 42 CFR 424.502 and the applicable sections of any enrollment applications. These adverse legal actions include Medicare imposed revocations, suspensions or revocations of medical licensure by a state licensing authority, felony convictions, and exclusions/debarments from participation in Federal health care programs.

2. The Contractor shall research these adverse legal actions via any and all applicable sources including but not limited to state medical licensing boards and any legal search databases.

3. The Contractor shall employ and leverage a legal team (composed of attorneys, paralegals or other legal personnel) to effectuate all research into these adverse legal actions.

4. The Contractor shall coordinate with CMS all requirements for substantiation of identified adverse legal actions.

5. The Contractor shall develop training materials to educate the Medicare Parts A, B, C, , DME and Medicaid provider and supplier community on disclosure requirements on all enrollment applications.

6. The Contractor shall submit all training materials to CMS for approval prior to usage.

7. The Contractor shall obtain written approval from CMS prior to engagement with providers and their contact persons.

3.13.1.1 Adverse Legal Action Services’ Performance Standards

a) Standard: Execute requirements using a variety of innovative search tools.

b) Standard: Utilize best legal practices and commercial data.

c) Standard: Demonstrate efficiencies and improvements.

4 Special Requirements

This section describes the special requirements for this effort. The following sub-sections provide details of various considerations on this effort.

4.1 Transition

The contractor shall follow the transition plans submitted as part of the proposal for each task order award, and keep the Government fully informed of status throughout the transition period. Throughout the phase-in/phase-out periods, it is essential that attention be given to minimize interruptions or delays to work in progress that would impact the mission. The contractor must plan for the transfer of work control, delineating the method for processing and assigning tasks during the phase-in/phase-out periods.

4.2 Government Furnished Materials

The Government will make available the information and equipment upon issuance of task orders.

4.2.1 Government Furnished Information

CMS will authorize the Contractor access to the following types of government-furnished information (GFI) as information becomes available and when applicable to the Contractors work requirements:

o Provider/supplier enrollment data stored in the PECOS application (daily extract files with provider/supplier information pertaining to each site visit work request).

o PECOS application documentation

4.2.2 Contractor Access to CMS Facilities and Systems

CMS contractors who require access to CMS systems or a physical facility will be required to complete and submit an application electronically through CMS’s Enterprise User Administration (EUA) and Front End Interface (EFI). The CMS COR will approve contractor access through the same system.

4.2.3 Government Furnished Equipment (GFE)

The Government may provide GFE upon issuance of task orders.

4.2.4 Government Furnished Facilities

The Government shall not furnish any facilities for this contract award.

4.3 Quality

This section describes the Quality Control components for this effort. The following sub-sections provide details of various considerations on this effort.

4.3.1 Quality Control

The Contractor shall develop a Task/Delivery Order and maintain an effective quality control program (QCP) to ensure services are performed in accordance with the PEO-IDIQ contract and this SOW. The Contractor shall develop and implement procedures to identify, prevent, and ensure non-recurrence of defective services. The Contractors QCP is the means by which he assures himself that his work complies with the requirement of the contract.

The finalized QCP will be accepted by the Government at the time of the award of the Task/Delivery Order. The Contracting Officer may notify the Contractor of required modifications to the plan during the period of performance. The Contractor then shall coordinate suggested modifications and obtain acceptance of the plan by the Contracting Officer. Any modifications to the program during the period of performance shall be provided to the Contracting Officer for review no later than ten (10) business days prior to the effective date of the change. The QCP shall be subject to the Governments review and approval. The Government may find the QCP "unacceptable" whenever the Contractors procedures do not accomplish quality control objective(s). The Contractor shall revise the QCP within ten (10) business days from receipt of notice that the QCP is found "unacceptable."

4.3.1.1 Quality Assurance Surveillance Plan (QASP)

The Government shall monitor the Contractors performance under all Task Orders in accordance with the Governments QASP process.

4.4 Section 508 Accessibility of Electronic and Information Technology

This contract is subject to Section 508 of the Rehabilitation Act of 1973 (29 U.S.C. 794d) as amended by the workforce Investment Act of 1998 (P.L. 105-220).