J.1.A List of Key Definitions.docx

Attachment J.1.A Listing of Key Definitions – Appendix A to SOW

RFP # 75FCMC19R0023

A. KEY DEFINITIONS

Definitions critical to understanding this Statement of Work (SOW) are provided in this section. Get more information about Medicare on the CMS Home Page (https://www.cms.gov/). In this SOW:

Acceptable Quality Level (AQL) means the minimum level of (expected) performance that is acceptable. Failure to achieve this level of performance renders the service being provided by the contractor unacceptable.

Activity means a unit or description of work usually done by one or more persons belonging to the same office, branch or other small group. Statement of work (SOW) functional activities usually involve consistent process inputs, process steps, and process outputs.

Adjudicate means processing a claim to a finalized status. Adjudicate also means the process of rendering a decision on a pending appeal. Sometimes the term is used to refer to making a decision on an issue/question that does not have administrative appeal rights.

Administrative Qualified Independent Contractor (AdQIC) means a contractor that provides administrative services in support of the Qualified Independent Contractors (QICs) which include training, updating protocols, reporting, long-term case file storage, referrals to the Medicare Appeals Council within the Departmental Appeals Board (DAB), notifying Medicare Administrative Contractors (MACs) to effectuate Administrative Law Judge (ALJ) and Medicare Appeals Council decisions, and coordinating various QIC, MAC, and the Office of Medicare Hearings and Appeals (OMHA) activities.

Administrative Requirement means a general requirement related to the overall management and administration of the entity’s contract with the Centers for Medicare & Medicaid Services (CMS) (e.g., internal controls, systems security) and can be driven by Agency requirement, contract terms and conditions contract clause, contract amendment/modification, or legislation.

American National Standards Institute (ANSI) is an organization that accredits various standards-setting committees, and monitors their compliance with the open rule-making process that they must follow to qualify for ANSI accreditation. Health Insurance Portability and Accountability Act (HIPAA) prescribes that the standards mandated under it be developed by ANSI-accredited bodies whenever practical.

Appellant means the beneficiary, assignee or other person or entity that has filed and pursued an appeal concerning a particular initial determination. See 42 Code of Federal Regulations (CFR) 405.370.

Assignee means (1) A supplier that furnishes items or services to a beneficiary and has accepted a valid assignment of a claim or (2) A provider or supplier that furnishes items or services to a beneficiary, who is not already a party, and has accepted a valid assignment of the right to appeal a claim executed by the beneficiary. See Code of Federal Regulations (CFR) 42 405.902.

Benefit Account Balance means any daily collected balance (positive or negative) that may exist in the benefits account after all items presented for payment have been cleared. The earnings or loss resulting from any such balances will be included in the quarterly computation to adjust the Federal Health Insurance (FHI) time account.

Benefit Coordination and Recovery Center (BCRC) The BCRC performs Medicare Secondary Payer (MSP) liability insurance (including self-insurance), no-fault insurance, and workers' compensation (Non-Group Health Plan) recovery case work. The BCRC also consolidates the activities that support the collection, management, and reporting of other insurance coverage for Medicare beneficiaries. The BCRC takes actions to identify the health benefits available to a Medicare beneficiary and coordinates the payment process to prevent mistaken payment of Medicare benefits. The BCRC does not process claims, nor does it handle any group health plan related mistaken payment recoveries or claims specific inquiries. The Medicare Administrative Contractors (MACs) are responsible for processing claims submitted for primary or secondary payment. The BCRC does not process claims, nor does it handle any mistaken payment recoveries with respect to Group Health Plan (GHP) recoveries or claims specific inquiries. The Commercial Repayment Center (CRC) contract handles MSP GHP recovery case work. Once the BCRC has completed its initial MSP development activities, it will notify the CRC regarding a GHP MSP occurrence and will notify the BCRC regarding a liability, workers’ compensation, or no-fault MSP occurrence (i.e., a Non-GHP MSP occurrence). The MACs are responsible for processing claims submitted for primary or secondary payment.

Bill - see Claim.

Billing Error means an error that prevents a claim or bill from being properly adjudicated.

Business Requirements Notification means a Centers for Medicare & Medicaid Services (CMS) Change Request (CR) form used to communicate new instructions or updates or clarifications to existing instructions.

Call Center Operations (CCO) The CCO contractor responds to inquiries from the Centers for Medicare & Medicaid Services’ (CMS's) customer service population. The Contractor supports multi-channel operations that receive and respond to inquiries, providing information and services through various channels including telephone, mail, email, Telecommunications Device for the Deaf (TDD)/ Teletypewriter (Text Telephones) (TTY), fax, and web chat. The CCO fields inquiries for CMS programs such as 1-800 Medicare, the Medicare Modernization Act (MMA), the Health Insurance Marketplace, and other relevant programs.

Certificate of Medical Necessity (CMN) is a form or other document containing information required to show that an item is reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. CMNs also require other types of administrative information that may be useful for the contractor or other entity to ensure that the item billed was reasonable and necessary. A physician signature is required on these forms.

Change Request means a proposed or required change to the Centers for Medicare & Medicaid Services (CMS) policy or procedures.

Claim means a transaction submitted by a provider or beneficiary that meets all the requirements in 42 Code of Federal Regulations (CFR) 424.30-424.44 (https://www.gpo.gov/fdsys/granule/CFR-2012-title42-vol3/CFR-2012-title42-vol3-sec424-30). (See also recovery claim.)

Claims-related transaction means a transaction other than a claim, which the contractor must process. This includes but is not limited to Health Insurance Portability and Accountability Act (HIPAA) related transactions and Method Selection forms for home dialysis. Claims must be filed within the timely filing period.

Clean claim means a claim that does not contain a defect or issue requiring the Medicare Administrative Contractor to investigate or develop for additional information prior to adjudication. See the Social Security Action 1842 (c)(2)(B) (https://www.ssa.gov/OP_Home/ssact/title18/1842.htm).

Common Working File (CWF) is an integral part of Medicare claims adjudication prior to payment. The CWF system ensures that the beneficiary is entitled to either Part A or Part B benefits, depending on the type of claim submitted; the co-pay and/or deductible applied, if any, is accurate; services are appropriate based on frequency; and benefits are available for the services submitted on the claim.

Complaint. See either Fraud and Abuse Complaints or Provider Complaint.

Comprehensive Error Rate Testing (CERT) CERT is a Centers for Medicare & Medicaid Services (CMS) program initiated to monitor the accuracy of Medicare Fee-for-Service (FFS) payments. The CERT contractor calculates the error rate for the Medicare Administrative Contractor (MAC). In order to gain insight into the causes of errors, CMS produces a national paid claims error rate, a contractor specific error rate, and provider compliance error rates. For more information, search for the Improper Medicare Fee-for-Service Payment Report on the CMS Home Page (https://www.cms.gov/) and to Internet Only Manual (IOM) Pub 100-8 Chapter 12 (http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/pim83c12.pdf).

Complex Beneficiary Inquiries represents those inquiries (telephone or written) from Medicare beneficiaries that cannot be resolved by the Call Center Operations (CCO) because additional research is required that the Customer Service agents do not have access to and/or there is no desktop scripting that exists that addresses the issue.

Confidential Notification means a Centers for Medicare & Medicaid Services (CMS) Change Request (CR) form used to request system or non-system changes that are not to be shared with the Medicare provider or beneficiary community.

Cost Report Acceptability means a review whose objective is to see whether a provider who is required to submit a cost report has submitted a complete and acceptable cost report in a timely manner.

Critical Edits means edits that search for data in a submission to determine whether the submission has met the requirements to be considered a claim, in accordance with 42 Code of Federal Regulations (CFR) §424.30 - §424.45 (http://www.gpo.gov/fdsys/granule/CFR-2012-title42-vol3/CFR-2012-title42-vol3-sec424-30).

Cutover means the actual point at which the outgoing contractor ceases Medicare claims payment operations and the new contractor begins to perform its Medicare claims payment functions.

Days means Federal business days unless otherwise specified.

Denied Claim means a claim that has been fully adjudicated. The contractor determines that payment on the claim shall not be made, either in full or in part. Denials are made based on Medicare rules and regulations, and such determinations can be appealed.

Desk Review means an analysis of the provider’s cost report to determine its adequacy and completeness, accuracy, and reasonableness of the data recorded, and a summary of review results to either settle the cost report without field audit (including any problem resolution) or to determine the extent to which field audit verification, including an on-site review, is required.

Determination - see Initial Determination, Medicare Secondary Payer (MSP) Determination, or Determination of Program Eligibility.

Determination of Program Eligibility means a Centers for Medicare & Medicaid Services (CMS) action that determines whether a prospective provider that must execute a health insurance benefits agreement meets all federal requirements necessary for participation in the Medicare program and is eligible to submit claims for covered services furnished to Medicare beneficiaries. A determination of Program Eligibility is based on satisfactory completion of the provider enrollment process, a certification of compliance, and a civil rights clearance.

Developing claims happens when incomplete or invalid information is detected on a claim at the front-end of the claims processing system, causing the Medicare Administrative Contractor (MAC) to suspend and develop the claim by requesting corrections and/or medical documentation from the supplier or provider of service. If the MAC receives the corrections and/or medical documentation within 45 days, the MAC will process the claim. Otherwise, the MAC will return the suspended portion of the claim and notify the supplier or provider of service via Remittance Advice (RA).

Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) are items and services the claims for which are mainly processed by Durable Medical Equipment (DME) Medicare Administrative Contractors (MACs) per Federal regulations at 42 CFR 421.210. Claims for implanted durable medical equipment or implanted prosthetic devices are processed by A/B MACs, and claims for durable medical equipment furnished by home health agencies are processed by Home Health MACs.

Durable Medical Equipment Medicare Administrative Contractor (DME MAC) means a MAC contractor that processes Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) claims.

DME Information Form (DIF) is a document containing information required by the Durable Medical Equipment (DME) Medicare Administrative Contractors (MAC) to be submitted to show that an item is reasonable and necessary. DIFs contain questions that reflect the local medical review policy for the item being billed. DIFs also require other types of administrative information that is useful for the DME MAC or other entity to ensure that the item billed was reasonable and necessary. DIFs are signed by the supplier only and do not require a physician signature.

Effectuate means for the MAC to issue a payment or to change liability for an item or service after an initial determination or a subsequent appeals decision has been reversed on appeal. See Internet-Only Manual (IOM) Pub. 100-04, Chapter 29, § 320.9.

Federally Qualified Health Centers (FQHC) are facilities that are engaged primarily in providing primary and preventive services that are typically furnished in an outpatient clinic. FQHCs include physician, nurse practitioner, physician assistant, certified nurse midwife, clinical psychologist, and clinical social worker services as well as services and supplies furnished incident to FQHC practitioner services. FQHCs provide services to people with Medicare, Medicaid, State Children’s Health Insurance Programs (SCHIP), and the uninsured in underserved rural and urban communities, and Indian outpatient health programs. FQHCs are paid under the FQHC Prospective Payment System (PPS) payment methodology.

Field Audit means an on-site examination of financial transactions, accounts, and reports as they relate to the Medicare cost report in order to test the provider's compliance with applicable Medicare laws, regulations, manual instructions and directives. Field Audits follow the CMS approved audit programs.

Finalized status means a final decision to pay, pay in part, or deny a claim.

Fraud, Waste or Abuse Complaints A complaint is a statement, oral or written, alleging that a provider, supplier, or beneficiary received a Medicare reimbursement or benefit to which he or she is not entitled under current Medicare law, regulations, or policy. Included are allegations of misrepresentation and violations of Medicare requirements applicable to persons or entities that bill for covered items and services. Additional examples are provided in Internet-Only Manual (IOM) 100-8, Chapter 4.6.1.

Freestanding home health agency refers to an entity that furnishes home health services that are not integrated with any other entity as a main provider, a department of a provider, remote location of a hospital, satellite facility, or a provider-based entity.

Freestanding Hospice refers to an entity that furnishes hospice services that is not integrated with any other entity as a main provider, a department of a provider, remote location of a hospital, satellite facility, or a provider-based entity.

Function means a unique operation, which is separately identifiable, such as Claims and/or Bills Payment, Appeals, etc. Functions consist of a series of activities.

Functional Requirement means a requirement that is part of the Medicare Operations process such as Bills Payment, Appeals, and Medical Review, etc. Each functional area represents a unique operation consisting of activities driven by Agency requirements outlined in the Medicare manuals.

Good cause means if an appeal request is filed late, the applicable MAC may extend the time limit for filing an appeal if good cause is shown. The Medicare Administrative Contractor (MAC) resolves the issue of whether good cause exists before taking any other action on the appeal. A finding by the MAC that good cause exists for late filing for the redetermination does not mean that the party is then excused from the timely filing rules for the reconsideration. Refer to Internet-Only Manual (IOM) 100-04, Chapter 29 §§ 240.2 and 240.3 for examples of situations that might constitute the existence of “good cause”.

Health Insurance Claim Number (HICN) means the number assigned by the Social Security Administration to an individual identifying him/her as a Medicare beneficiary.

This number is shown on the beneficiary’s insurance card and is used in processing Medicare claims for that beneficiary. This number will be retired with the implementation of the new Medicare card initiative. The new beneficiary identifier will be called the Medicare Beneficiary Identifier (MBI).

Health Professional Shortage Areas (HPSAs) Are geographic areas, or populations within geographic areas, that lack sufficient health care providers to meet the health care needs of the area or population. HPSAs identify areas of greater need throughout the United States so that limited resources can go to those areas. The Health Resources and Services Administration (HRSA) designates areas as HPSAs based on census tracts, townships, or counties. The Medicare HPSA Physician Bonus Program pays a 10 percent bonus to physicians furnishing services in geographic primary care and mental health HPSAs.

Healthcare Integrated General Ledger Accounting System (HIGLAS) means a single, unified general ledger accounting system that will support all Medicare Administrative Contractor (MAC) contractors and Centers for Medicare & Medicaid Services (CMS) central office administrative accounting.

Home Health Agency means a public agency or private organization, or a subdivision of such an agency or organization, which meets the requirements described in Internet-Only Manual (IOM) Pub 100-01, Chapter 5, §50 (https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/ge101c05.pdf).

Home Health and Hospice (HH+H) Workload means workload that is part of the contract for four of the A/B Medicare Administrative Contractors (MACs). This workload involves paying home health and hospice bills. They may also review claims for medical necessity and make a referral to a Quality Improvement Organization (QIO) if they receive a quality complaint.

Hospice means a public agency or private organization or a subdivision of either that is primarily engaged in providing care to terminally ill individuals and meets the conditions of participation for hospices, and has a valid provider agreement.

Hospital Payment Monitoring Program (HPMP) is one of ten initiatives included in the Comprehensive Plan for Program Integrity. The primary goal of HPMP is to continue the surveillance system that allows the Centers for Medicare & Medicaid Services (CMS) to continue to produce accurate and reliable estimates of payment error at the State and National level for inpatient acute care hospital services.

Implementation means the period of time beginning with the award of the Medicare Administrative Contractor (MAC) contract and ending with the operational date of the MAC. During this period, the MAC performs all of the activities specified in its implementation project plan to ensure the effective transfer of Medicare functions from the outgoing contractor(s). See Workload Transition.

Implementation Guide (IG) means a document explaining the proper use of a standard for a specific business purpose. The X12N Health Insurance Portability and Accountability Act (HIPAA) IGs are the primary reference documents used by those implementing the associated transactions, and are incorporated into the HIPAA regulations by reference.

In-House Audit means an examination of financial transactions, accounts, and reports as they relate to the Medicare cost report to test the provider's compliance with applicable Medicare laws, regulations, manual transactions, and directives that is performed at the contractor's location. The in-house audit usually requires limited records. In-House Audits follow the CMS approved audit programs.

Incomplete/invalid claims means claims that are missing critical information (e.g., Medicare Beneficiary Identifier (MBI), procedure code) or that include non-compliant values, and therefore do not meet the definition of a claim. Such claims are returned to the provider and may be corrected and resubmitted, but do not have appeal rights.

Inherent Reasonableness (IR) means an authority granted to the Centers for Medicare & Medicaid Services (CMS) whereby excessively high or low fee schedule amounts can be adjusted to more fairly represent the market.

Initial Determination generally means a decision made to pay in full, pay in part, or deny a claim. However, there are other actions that are also considered initial determinations and there are specific regulatory provisions defining what constitutes an initial determination for purposes of fee-for-service administrative appeal rights. See specifically 42 Code of Federal Regulations (CFR) 405.924 and 405.926 (https://www.gpo.gov/fdsys/pkg/CFR-2010-title42-vol2/pdf/CFR-2010-title42-vol2-sec405-924.pdf).

Institutional claims means claims for services that are submitted by institutional providers using the Health Insurance Portability and Accountability Act (HIPAA) institutional claim standard format or occasionally on a CMS-1450 (UB-04) paper claim form (https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R1104CP.pdf). These claims may be paid from either the Medicare Part A or Part B trust fund.

Institutional providers means hospitals and other facilities that must submit institutional claims to Medicare for Fee-for-Service (FFS) processing.

Interface means an entity the contractor must interact with to ensure consistency of Medicare program operations.

Interface Requirement means a requirement that necessitates a mechanism (e.g., contract clause, Joint Operating Agreements (JOA), Service Level Agreements (SLA)) to address ongoing activities contractors must conduct, and/or entities they must interact with to ensure consistency of Medicare program operations. When there are interdependencies, these interface requirements serve to ensure that all parties understand their respective responsibilities.

Joint Operating Agreement (JOA) means an agreement between two or more contractors working for the Centers for Medicare & Medicaid Services (CMS) who must interact with each other on an equal basis. CMS may or may not be a signatory to the JOA.

Jurisdiction means the defined geographic territory for which the Medicare Administrative Contractor (MAC) processes claims from institutional providers, physicians, practitioners and suppliers.

Jurisdiction Operational Start Date means the date that the Medicare Administrative Contractor (MAC) contractually assumes the Medicare functions from all outgoing contractors in its jurisdiction.

Letter-of-Credit means a legal reservation of funds on deposit in the Federal Reserve Bank (Standard Form 1193) that covers payments for which the contractor has contracted to pay by issuing checks and authorizing electronic funds transfer.

Limitation of Liability (LOL) means a restriction on liability for payment protecting either Medicare beneficiaries or providers based on the Social Security Act section 1870 (https://www.ssa.gov/OP_Home/ssact/title18/1870.htm) and section 1879 (https://www.ssa.gov/OP_Home/ssact/title18/1879.htm).

Local system edits means adaptations to the shared system, approved by the Centers for Medicare & Medicaid Services (CMS), and made by the contractor, to—

· Communicate with providers via remittance advice and beneficiaries via Medicare Summary Notice (MSN),

· Implement local coverage determinations, and

· Workaround shared system limitations.

Low/no Medicare utilization cost reports means a provider that either has not furnished any covered services to Medicare beneficiaries during the entire cost reporting period or that had low utilization of covered services by Medicare beneficiaries in a reporting period and received correspondingly low interim reimbursement payments. The cost reports required for these providers would be less than a full cost report, as authorized by the contractor. See Centers for Medicare & Medicaid Services (CMS) Pub. 15, Provider Reimbursement Manual, Part II (https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Paper-Based-Manuals-Items/CMS021935.html).

Mail means regular first-class mail delivered by the United States (U.S.) Postal Service, unless otherwise specified.

Material Weakness means failing to meet a control objective due to a significant deficiency in the design and/or operation of internal control policies and procedures.

Medicare Code Editor means a software editor employed to check the accuracy of claims relative to procedural/diagnostic coding on Medicare Fee-for-Service (FFS) inpatient claims.

Medicare data means any representation of information, in electronic or physical form, pertaining to Medicare beneficiaries, providers, physicians, suppliers, or practitioners, or information necessary for the contractual administration thereof, that is received, maintained, processed, manipulated, stored, or provided to others in the performance of the functions described in a Medicare contract. See also Medicare file and Medicare record.

Medicare Beneficiary Identifier (MBI) will replace the Social Security Number (SSN)-based Health Insurance Claim Number (HICN) on the new Medicare cards for Medicare transactions like billing, eligibility status, and claim status. The MBI is confidential like the SSN and should be protected as Personally Identifiable Information.

Medicare file means a set or collection of related Medicare records treated as a unit. See also Medicare data and Medicare record.

Medicare record means a collection of related items of Medicare data treated as a unit. See also Medicare data and Medicare file.

Medicare Reimbursement Principles means the Medicare cost reimbursement principles as set forth at 42 Code of Federal Regulations (CFR) 412.113 (https://www.gpo.gov/fdsys/granule/CFR-2011-title42-vol2/CFR-2011-title42-vol2-sec412-113).

Medicare Secondary Payer (MSP) means a series of statutory provisions that require other payers (including those that are self-insured) of medical items and services (e.g., group health plans, liability and no-fault insurers) to make payment before Medicare pays when certain specific conditions are satisfied.

Medicare Summary Notice (MSN) is a quarterly notice received every three months that people with Original Medicare receive in the mail for their Medicare Part A, Part B, and durable medical equipment services. The MSN provides an explanation of what the provider billed for, how much Medicare paid and the amount that is the beneficiary’s responsibility.

Medicare Secondary Payer (MSP) Claims Determination means the determination to deny payment or to pay conditionally due to an MSP situation.

Medicare Secondary Payer (MSP) Settlement means, in the context of Medicare Secondary Payer appeals, the trigger event for a Medicare Secondary Payer recovery claim.

Multi Carrier System (MCS) is the shared system used to process Medicare Part B claims for physician care, durable medical equipment, and other outpatient services nationwide. It interfaces directly with the Common Working File (CWF). It meets the Centers for Medicare & Medicaid Services’ (CMS’) core requirements for processing Medicare Part B claims, to include: data collection and validation, claims control, pricing, adjudication, correspondence, on-line inquiry, file maintenance, reimbursement, and financial processing.

National Provider Identifier (NPI) means a standard unique identifier for providers. The NPI is a numeric 10-digit identifier adopted by Health and Human Services (HHS) as the standard identifier for health care providers.

National Supplier Clearinghouse (NSC) means a contractor that enrolls Medicare Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) suppliers.

Next Generation Desktop (NGD) is the Web-based customer service desktop application via which Medicare Administrative Contractors (MACs) accept and track referrals of complex telephone and written inquiries referred by the Call Center Operations (CCO).

One-Time Notification (OTN) means a Centers for Medicare & Medicaid Services (CMS) Change Request (CR) form used to communicate one-time instructions to Medicare Administrative Contractors (MACs), Shared System Maintainers (SSMs), and the Common Working File (CWF) maintenance contractor.

Orthotics means rigid and semi-rigid devices, which are used for the purpose of supporting a weak or deformed body member or restricting or eliminating motion in a diseased or injured part of the body. Elastic stockings, garter belts, and similar devices do not come within the scope of the definition of a brace. Back braces include, but are not limited to, special corsets (e.g., sacroiliac, sacrolumbar, dorsolumbar corsets) and belts.

Other Than Clean Claims Any claim that does not meet the definition of clean claim. These are complete claims that require investigation or development by the contractor to be adjudicated.

Outgoing Contractor Workload Transition Activities Closeout means the time between the award of a jurisdiction to a new Medicare Administrative Contractor (MAC) and the end of the incumbent contractor’s Durable Medical Equipment (DME) MAC or A/B MAC contract. This period includes a set of defined activities to support the transition to the new contract.

Outpatient Code Editor (OCE) means a software editor employed to check the accuracy of claims relative to procedural/diagnostic coding on Medicare Fee-for-Service (FFS) outpatient institutional claims.

Paid Claims Error Rate means a rate that is based on dollars paid after the contractor made its payment decision on the claim/admission. It excludes any claim/admission that the contractor completely disallowed (Centers for Medicare & Medicaid Services (CMS) has reviewed the impact of these exclusions and determined that they have a negligible effect on the error rate.). The paid claims error rate is the percentage of dollars that contractor erroneously allowed to be paid and is a good indicator of how claim errors in the Medicare Fee-for-Service (FFS) program impact the trust fund. This error rate is based on dollars.

Performance Measure means a clearly defined qualitative or quantitative method for determining the level of performance that a contractor has actually achieved.

Performance Requirement means a clear and concise statement of a desired outcome. In this statement of work (SOW) performance requirements are identified as numbered subparagraphs in Section C.5.

Performance Standards means a clear and concise defined level of (expected) performance against which the quality of the contractor’s services can be determined.

Periodic Interim Payment (PIP) means a periodic payment made to certain Medicare institutional providers related to their cost and Medicare utilization and later reconciled against payment due when claims are received.

Periodic Review means the Centers for Medicare & Medicaid Services (CMS) reviews conducted at times determined to be appropriate for the circumstances.

Post-Cutover Period means the Medicare Administrative Contractor’s (MAC’s) first three months of Medicare operations, during which workload and performance are monitored and any problems with the implementation are resolved.

Professional claims means claims for services that must be submitted to Medicare for Fee-for-Service (FFS) processing in a Health Insurance Portability and Accountability Act (HIPAA) approved electronic claim standard format or sometimes on a CMS 1500 (02-12) paper claim form (https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS1500.pdf). These claims are paid only from the Medicare Part B trust fund.

Professional providers means physicians, practitioners, and suppliers that must submit professional claims to Medicare for Fee-for-Service (FFS) processing.

Prosthetics means artificial legs, arms, and eyes, including replacements if required because of a change in the patient’s physical condition. A terminal device (e.g., hand or hook) is covered under this provision when an artificial limb is required by the patient. Stump stockings and harnesses (including replacements) are also covered when these appliances are essential to the effective use of the artificial limb.

Prosthetic Devices means devices (other than dental) which are covered under Part B as a medical or other health service, as specified in the Social Security Act section 1861(s)(8) (https://www.ssa.gov/OP_Home/ssact/title18/1861.htm), and are devices that replace all or part of an internal body organ or replace all or part of the function of a permanently inoperative or malfunctioning internal body organ.

Provider means any Medicare provider (e.g., hospital, skilled nursing facility, home health agency, outpatient physical therapy, comprehensive outpatient rehabilitation facility, end-stage renal disease facility, hospice, physician, non-physician provider, laboratory, supplier, etc.) providing medical services covered under Medicare Part B. Any organization, institution, or individual that provides health care services to Medicare beneficiaries. Physicians, ambulatory surgical centers, and outpatient clinics are some of the providers of services covered under Medicare Part B.

Provider agreement means a Health Insurance Benefit Agreement, which is an agreement between the Secretary of the Department of Health and Human Services and a provider, in which the provider agrees to conform to Section 1866 of the Social Security Act (https://www.ssa.gov/OP_Home/ssact/title18/1866.htm) in order to receive payment under Title XVIII of the Social Security Act (https://www.ssa.gov/OP_Home/ssact/title18/1800.htm).

Provider-based determination means a determination that a facility or organization, which has been created by or acquired by a main provider to furnish health care services different from the main provider’s, merits provider-based status for payment purposes.

Provider-based home health agency means a provider of home health services that is either created by, or acquired by, a main provider for the purpose of furnishing health care services of a different type from those of the main provider under the ownership and administrative and financial control of the main provider, in accordance with the provisions of 42 Code of Federal Regulations (CFR) 413.65 (https://www.gpo.gov/fdsys/pkg/CFR-2011-title42-vol2/pdf/CFR-2011-title42-vol2-sec413-65.pdf).

Provider-based hospice means a provider of hospice services that is either created by, or acquired by, a main provider for the purpose of furnishing health care services of a different type from those of the main provider under the ownership and administrative and financial control of the main provider, in accordance with the provisions of 42 Code of Federal Regulations (CFR) 413.65 (https://www.gpo.gov/fdsys/pkg/CFR-2011-title42-vol2/pdf/CFR-2011-title42-vol2-sec413-65.pdf).

Provider complaint means a provider’s complaint about the contractor’s performance. Verified provider complaints are used as a measure of the quality of the contractor’s performance under this statement of work (SOW).

Provider compliance error rate means a rate that is based on how the claims look when they first arrive at the contractor, before the contractor applies any edits or conducts any reviews. The provider compliance error rate is a good indicator of how well the contractor is educating the provider community because it measures how well providers prepare claims for submission. This error rate is based on dollars. For more information on the calculation of this error rate please search for the Improper Medicare Fee-for-Service Payment Report on the CMS Home Page (https://www.cms.gov/).

Provider Contact Center (PCC) means a provider customer service center responding to telephone and written provider inquiries.

Provider Enrollment Chain and Ownership System (PECOS) is a Medicare Provider Enrollment system that captures information contained within the Medicare Enrollment Forms. It is a secured system that provides access to specified functions for authorized users.

Prospective Payment System (PPS) means a method of reimbursement in which Medicare payment is made for certain institutional benefits based on a predetermined, fixed amount. The payment amount for a particular service is derived based on the classification system of that service.

Quality Improvement Organization (QIO) is a group comprised of health quality experts, clinicians, and consumers that are paid by the federal government to review and improve the effectiveness, efficiency, economy, and quality of services delivered to Medicare beneficiaries as described in Title 11 of the Social Security Act.

Qualified Independent Contractor (QIC) means an entity which contracts with the Secretary in accordance with Section 1869 of the Act to perform reconsiderations under 42 Code of Federal Regulations (CFR) 405.960 through 405.978. See CFR 405.370(b).

Quarterly Releases means four quarterly software releases (generally released on the first Monday of the calendar year quarters) used to implement changes to the Shared Systems and the Common Working File (CWF).

Reconsideration means the second level of the Medicare fee-for-service claims appeals process. It is an independent review of the redetermination decision, including the initial determination, and is conducted by a Qualified Independent Contractor (QIC) (a separate entity from the Medicare Administrative Contractor). The person conducting the reconsideration must not have been involved in either the initial determination decision or the redetermination decision. See Code of Federal Regulations (CFR) 405.960 through 405.978.

Recovery claim means certain debts (particularly Medicare Secondary Payer (MSP) debts) owed to the Medicare program.

Recurring Update Notification means a Centers for Medicare & Medicaid Services (CMS) Change Request (CR) form used to communicate regularly scheduled or annual instructions, changes and updates to CMS-supplied software and software documentation, fee schedules, the federal interest rate percentage, and code sets and other intermittently issued information.

Redetermination means the first level of the Medicare fee-for-service claims appeals process. It is an independent review of the initial claims determination and is conducted by the Medicare Administrative Contractor. The individual(s) conducting the redetermination must not have been a part of the initial determination decision. A redetermination decision is considered to be part of the initial determination. See Code of Federal Regulations (CFR) 405.948.

Rejected claim - Either a claim received with incomplete or invalid information or a claim line that has been determined to be an exact duplicate are rejected. A rejected claim or claim line does not have appeal rights.

Return to Provider (RTP) is an electronic process used by a Medicare Administrative Contractor (MAC) to return a Part A claim to the provider for incomplete or invalid information, with an explanation of the error(s) and how to correct them prior to resubmission. No remittance advice (RA) is issued as part of this process, and no record of the claim is retained in the system.

Returned claim happens when the claims processing system detects incomplete or invalid information on a Part B claim, causing the Medicare Administrative Contractor (MAC) to issue a remittance advice to the supplier or provider or service notifying them the claim is rejected, with an explanation of the error(s) and how to correct them prior to resubmission. A record of the claim is retained in the system.

Rural Health Clinics (RHCs) are facilities that are engaged primarily in providing primary and preventive services that are typically furnished in an outpatient clinic. RHCs include physician, nurse practitioner, physician assistant, certified nurse midwife, clinical psychologist, and clinical social worker services as well as services and supplies furnished incident to RHC practitioner services. To become certified as an RHC, a clinic must be located in a medically underserved or shortage as determined by Health Resources and Services Administration (HRSA), and an area that is not urbanized, as determined by the Census Bureau. RHCs are paid under the RHC All-Inclusive Rate payment methodology.

Segment means the Part A or Part B workload that a given outgoing contractor processes in any one jurisdiction and that would be assumed by the contractor. It also refers to a block of a specific type of information in X12 transaction format.

Service Level Agreement (SLA) means a written document between a vendor that offers a service (e.g. data center, cable company, telecommunication company) and its customer about the quality, quantity and timeliness of the delivery of the product or service the customer is buying.

Services Processed Error Rate means a rate that is based on services processed and measures whether the contractor made appropriate payment decisions on claims. All sampled claims are included (whether the contractor paid or denied them). This is a gross rate where the number of services overpaid is added to the number of services underpaid. The services processed error rate is a good indicator of how well the contractor is doing overall at finding and preventing claim errors. This error rate is based on numbers of services.

Settlement means the process of incorporating adjustments to a cost report derived from the contractor’s review and issuing a Notice of Program Reimbursement (NPR) or Revised NPR. (For Medicare Secondary Payer (MSP), see MSP settlement.)

Shared System (Previously known as Standard System) means systems provided by CMS to process Medicare claims. For professional claims (e.g., physician claims), the system is Multi Carrier System (MCS); for institutional providers (e.g., hospitals and nursing homes), the system is the Fiscal Intermediary Standard System (FISS), and for Durable Medical Equipment (DME) Medicare Administrative Contractors (MACs), the system is the ViPS Medicare System (VMS).

Skilled Nursing Facility (SNF) means an institution (which meets specific regulatory certification requirements) which primarily provides inpatient skilled nursing or rehabilitative services but does not provide the level of care or treatment available in a hospital.

Small Provider means a provider of services with fewer than 25 full time equivalent employees or a supplier with fewer than 10 full time equivalent employees.

Stakeholders means beneficiaries, care givers, beneficiary family members, advocacy groups, providers, insurers, Medicare contractors, industry associations, employers, other third party administrators, other third party payers, data users, standards setting organizations, Centers for Medicare & Medicaid Services (CMS), Medicaid, Health and Human Services (HHS), the HHS Office of the Inspector General, other Government Agencies, the General Accounting office, Congress, and taxpayers.

Supplier means a physician or other practitioner, a facility, or other entity (other than a provider of services) that furnished items and services under Medicare (e.g., Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS)) and/or specific medical services (i.e., independent diagnostic testing facility, laboratory services, and ambulance services). As used in this statement of work (SOW), the term provider encompasses supplier. See Provider.

Supplier Complaint means a supplier’s complaint about the Medicare Administrative Contractor’s (MAC’s) performance. Supplier complaints are used as a measure of the quality of the MAC’s performance under this statement of work (SOW).

Suspended Claim means a claim that is flagged by the claims processing system and must be resolved before the claim can be processed to completion. A suspension can occur due to a code placed on the claim by the provider.

System Development Life Cycle (SDLC) means the process of developing information systems through multiple phases, including investigation of the need, requirements analysis, design, testing, and implementation. SDLC is also known as information systems development or application development.

System Security means protecting any Federal information and information systems, which include information technology (IT) systems, from unauthorized access, use, disclosure, disruption, modification, or destruction through physical, technical and/or administrative safeguards.

Technical Direction Letter (TDL) means a formal Centers for Medicare & Medicaid Services (CMS) communication vehicle used for administrative announcements, emergency alerts, and one-time informational requests that do not involve shared system changes.

Transition Requirements means requirements that encompass all of the tasks an incoming contractor must perform to assume from a current contractor all aspects of its Medicare fee-for-service claims processing operation.

Technical Advisory Group (TAG) means a workgroup containing experts in the subject area and generally including staff from the contractor, Centers for Medicare & Medicaid Services (CMS) central and Regional offices, other Medicare Administrative Contractors (MACs) and the shared systems maintainers.

Uniform Desk Review (UDR) means the objective of the UDR is to determine whether the cost report can be settled without audit, and to determine the scope of the In-audit or on-site review, as appropriate. The UDR comprises an accessibility checklist, a clerical review, selection of professional desk review type, either a limited professional desk review or a full professional desk review, and a summary of UDR exceptions.

Unified Program Integrity Contractor (UPIC) A contractor that performs fraud, waste and abuse detection, deterrence and prevention activities for Medicare and Medicaid. Their duties include, but are not limited to, medical review, administrative actions to include but not limited to payment suspensions, revocations, and referrals to Law Enforcement.

Virtual Data Center (VDC) A data center serves as a platform for claims processing software systems for Medicare claims. Traditionally, the Medicare contractors either operated their own data centers or contracted out for these services. As part of the Centers for Medicare & Medicaid Services’ (CMS’) contracting reform initiative, CMS reduced the number of data centers from more than one dozen separate smaller centers to two large VDCs. CMS manages these contracts.

VMS Standard System means the Viable Information Processing System (ViPS) Medicare system used to process Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) claims.

Workload Transition means the entire scope of activities associated with moving Medicare functions from one, or several, Medicare contractor(s) to another. See Implementation.

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