J.1.C Fee-For-Service Shared System Base Functions.docx

Attachment J.1.C Fee-for-Service Shared System Base Functions – Appendix C to SOW

RFP # 75FCMC19R0023

· Maintenance and operation of non-z/OS platforms’ security needs, i.e., Windows, Unix/Linux, etc.

· Data Center security ID and password that controls access into the data center system – including Time Sharing Option (TSO)/ Interactive System Productivity Facility (ISPF) access, Network Data Mover (NDM)/file transfer systems’ user id’s and file access controls, access into the Customer Information Control System (CICS) regions, access to CICS transactions, and read/write access to files.

· Coordinate with other datacenters, for needed security accesses, such as real-time accesses for CICS-to-CICS systems transactions (across different datacenters).

· Guarantee the access separation and other user and batch process’ access restrictions, between different companies’ data being stored and processed at the VDC.

· Data Center security Machine-ID and non-expiring password that controls access into the data center for functions such as Interactive Voice Response (IVR), Next Generation Desktop (NGD), and various Medicare Administrative Contractor (MAC) provider and supplier portals.

Telecommunications

· Works with Centers for Medicare & Medicaid Services (CMS) approved contractors and Maintainers as necessary to establish batch and interactive connectivity between the data centers.

· Implement and maintain firewalls, data connectivity with outside vendors and other entities, and other network management systems supporting the Virtual Data Center (VDC) functions and services.

· Implement and maintain secure connectivity into the VDC via Virtual Private Network (VPN) and two-factor authentication services.

· Provision and mitigate for such risks and events as: disasters (recovery), network and power outages, work-site outages, and test/drills for such events. Prepare and support other organizations that we connect with, with their risks, events, and testing efforts.

· The VDC receives files transmitted from CMS approved contractors, BDC, Maintainers, and 3rd Party Vendors.

MCS and FISS accept CMS’ X12 flat files for HIPAA EDI transactions created from the translation of ANSI ASC X12N version 4010A.1 format, as well as other EDI transactions as directed by CMS. (There are currently no ASC X12 version 0041010/004010A1 EDI transaction formats supported other than those implemented per the HIPAA requirements, but CMS could direct at some point that supplemental EDI transaction standards not yet adopted under HIPAA be supported as well.)

At present, MCS and FISS software support a path for each single version of the ASC X12 HIPAA EDI standards. Specifically the 00410/004010A1 and the 005010 EDI transactions do not process in the same set of programs. When a subsequent version is adopted as a national standard under HIPAA, it will be necessary for the Contractor to support both the new and the old versions until all users are required to use the new version exclusively.

Perform pre-pass editing and reporting for the Version 00410/004010A1. This activity is separate and distinct from the 005010 activity. The Contractor shall continue to support all versions until appropriate sun setting notice has been provided.

· The Virtual Data Center (VDC) executes the jobs necessary to back up the Interface files to any recreate instances for the MAC.

· The Virtual Data Center (VDC) executes the jobs necessary to create INIT Files so that the System can run without Issues in an event when the file is not transmitted by the CMS approved contractors, Baltimore data Center (BDC), Maintainers and 3rd Party Vendors.

MCS furnishes the Professional Provider Telecommunication Network (PPTN) application for provider inquiry of claims status information via a Direct Data Entry (DDE) type screen and MCS also furnishes a link to the Common Working File (CWF) via a maintained DDE screen established to request and receive beneficiary eligibility information.

Creation of crossover data for the Benefits Coordination & Recovery Center (BCRC)

Execution of jobs to transmit the crossover flat file claims data to the BCRC via the Medicare telecommunications network.

· Automated Development System (ADS), including a base letter file selected from an existing user

· Generation of standard International Business Machines (IBM) Advanced Function Presentation (AFP) mixed mode or Xerox JDL/JDE print file containing development letters (English or Spanish) that support use of contractor-maintained optical mark recognition (OMR) marks or 3 of 9 barcodes

· Execution of the jobs to transmit the base print output to the contractor local data center.

· Transmit the Base Prints for Meta Data to the Next Generation Desktop (NGD).

On-line work scheduler

Suspense document print file

Weekly EOLQA sampling

Correspondence application that provides ability to track telephone and written correspondence

· Execution of the jobs to extract the contractor-specific fee schedule data.

· Execution of the Fiscal Intermediary Standard System (FISS) Health Care Common Procedure Coding (HCPC) Jobs at the VDC with all the extracted files and effective dates to load the HCPC File as the files become available in a Technical Direction Letter (TDL)/Change Request (CR).

· Work with the Medicare Administrative Contractor (MAC)/Maintainer on an agreed upon scheduled to run Jobs in order to load during Quarterly and Off Quarterly schedule. Work with MAC to transmit the file and reports to review.

· Work with the MAC on timing of running the Mass Adjustments.

· Execution of jobs to create adjustments from the Expert Claims Processing System (ECPS)

· Work with the MAC on timing of running the Mass Adjustments.

MSP automated payment calculation

Identification of MSP recovery claims via Internal Revenue Service (IRS)/Social Security Administration )SSA) Data Match and retroactive recovery with automated history searching

· Demand packages in a basic AFP mixed mode or Xerox Dynamic Job Descriptor Entry (DJDE) print file, along with mailing label print files for certified and non-certified mail

· Associated folder label print file Execution of the jobs to transmit the base print output to the contractor’s print site (if routing is not done via the Job Control Language (JCL))

Receipt and installation of Electronic Correspondence Referral System (ECRS) software.

· Workload and Performance/ Production Performance Monitoring System (PULSE) file;

· Appeals;

· Medical Review Workload;

· Medical Review Savings;

· Program Integrity Management Reporting System (PIMR);

· Medicare Secondary Payer (MSP) Savings;

· Chief Financial Officer (CFO)

· Execution of the jobs to transmit the Program Integrity Management Reporting System (PIMR) data to CMS’ PIMR contractor

· Execution of the jobs to transmit the Correct Coding Initiative (CCI) report to CMS’ CCI contractor

· Execution of the jobs to transmit the data to CMS’ PULSE contractor

· Retrieval of the Daily Export Extract file from the PECOS (one per Contractor number)

Creation of yearly participating (PAR) provider counts

· Creation of a weekly mammography report

· Validation of certification numbers for mammography facilities Execution of the jobs to retrieve the Mammography Quality Standard Act (MQSA) File from the CMS data center

Multi Carrier System (MCS) creates weekly tapes for the Railroad Retirement Board (RRB) containing provider extract data

· Creation and execution of the jobs to transmit the extracted data to contractor data center

Virtual Data Center (VDC) also supports the following:

· Beneficiary Data Services (BDS) process

· Fraud Prevention System (FPS)

· New Medicare Card processes

· CWF Host Implementation and Correction Requests (HICR)

· Execution of bank-specific interfaces for Issues file (optional, with Centers for Medicare & Medicaid Services (CMS) approval)

· Execution of the jobs to transmit the issues file to the bank or contractor data center

· Receipt of the Clears file from the bank (optional)

· Execution of bank-specific interfaces for Clears file (optional, with CMS approval)

Stale date processing

Mailroom-ready output document files, suitable for printing on International Business Machines (IBM) equipment, that have:

· Basic Advanced Function Presentation (AFP) mixed mode print file;

· Parameters to control additional mail finishing marks;

· Optical Mark Recognition (OMR) coding or 3 of 9 barcodes for outgoing financial documents;

· Separate checks, Medicare Summary Notices (MSNs), and remittance with AFP mixed mode formatted print streams;

· English language printed output for all documents, and Spanish language for the beneficiary MSN;

· Base Presort processing Execution of the jobs to transmit the base print output to the contractor’s print site (if routing is not done via the Job Control Language (JCL))

— OR —

Mailroom-ready output document files, suitable for printing on Xerox equipment that have:

· Xerox print file;

· Parameters to control additional mail finishing marks;

· OMR coding or 3 of 9 barcodes for outgoing financial documents;

· MSNs and remittance with Xerox JDL/JDE formatted print streams;

· English language printed output for all documents, and Spanish language for the beneficiary MSN;

· Base Presort processing Execution of the jobs to transmit the base print output to the contractor’s print site (if routing is not done via the JCL)

Cash receipts processing

Accounts receivable processing

Accounts payable processing

· Execution of the jobs to transmit the ACH records to the bank or the contractor data center.

Health Professional Shortage Area (HPSA) processing which includes:

· Incentive checks in the same format as other special checks;

· Incentive payment reports;

· HPSA guideline monitoring reports;

· Suppression of HPSA checks for violators

· Notification of providers of those claims for which the HPSA bonus is being paid

· Accept standard format NCOA file used to update beneficiary address data

· Support of telecommunications with vendor

· Execution of vendor-specific interfaces for NCOA file (with Centers for Medicare & Medicaid Services (CMS) approval)

· Execution of the jobs to transmit the NCOA records to the NCOA vendor or the contractor data center.

Automated history search capability to interface with ARGUS

Sampling capability in support of focused medical review (online history plus 4 years of purged history)

Capability to retrieve information by beneficiary from purged history

Pioneer Accountable Care Organization Model (ACO)

Execution of the jobs to extract the data and transmit the data to the data storage location (with Centers for Medicare & Medicaid Services (CMS) approval)

Recovery Audit Contractor (RAC)

· Establish connection and Resource Control Facility (RACF) to send and accept files from these 3rd Party entities.

· Execution of the jobs to extract the data and transmit the data to the data storage location (with Centers for Medicare & Medicaid Services (CMS) approval)

The Provider Statistical and Reimbursement (PS&R)

· Establish connection and Resource Control Facility (RACF) to send and accept files from these 3rd Party entities.

· Execution of the jobs to extract the data and transmit the data to the data storage location (with Centers for Medicare & Medicaid Services (CMS) approval)

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