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Attachment J.1.G A/B MAC Performance Requirements Summary
RFP # 75FCMC19R0023
Jurisdiction E V.2.0
| C.5.1.3 Risk Management Plan |
| 1 |
| The Contractor’s Risk Management Plan is successful when it is submitted within 30 calendar days of the kick off meeting. |
| C.5.1.8.2 Consolidation of Local Coverage Determinations |
| 1 |
| Initial consolidation of inherited LCDs by subject area is successful when all LCDs are completed and the policies posted on the web 45 calendar days (or more) prior to the first segment cutover date. |
| C.5.1.8.2 Consolidation of Local Coverage Determinations |
| 2 |
| Notification of the provider community is successful when the Contractor provides the notice 45 calendar days (or more) prior to the policy cutover date. |
| C.5.3 Infrastructure Requirements |
| 1 |
| The infrastructure is successful when it is available during all required hours of operation. |
| C.5.3.1 Enterprise Data Center |
| 1 |
| The Contractor’s use of VDC (Virtual Data Center) is successful when it uses the operational processes and procedures the VDC establishes with its users. |
| C.5.4.3.4 Correct Deficiencies |
| 1 |
| The Contractor's corrective action procedures are successful when its weaknesses, findings, gaps, or other deficiencies are corrected within 90 calendar days of receipt of the final audit or evaluation report unless authorized by CMS otherwise. |
| C.5.4.4 Quality Assurance Requirements |
| 1 |
| The MAC shall establish a quality assurance program and implement quality control measures necessary to meet the requirements and standards documented in its contract with the Government. |
| C.5.4.5 Public Relations |
| 1 |
| The Contractor’s public relations plan is successful when its processes and procedures are used to address problem areas as they are identified. |
| C.5.4.5 Public Relations |
| 2 |
| The Contractor’s public relations plan is successful when general information developed by the Contractor concerning Medicare and its policies is approved by CMS before being distributed to stakeholders. |
| C.5.4.6.1 Responses to Congressional Inquiries |
| 1 |
| Congressional written inquiries are timely when 100% are answered within 10 business days, including any that may be received from a CMS RO. For those Congressional inquiries that cannot be answered in final within 10 business days, the Contractor shall issue an interim response within 10 business days explaining the reason for the delay. Any interim responses sent to Congressional inquiries shall count toward the Contractor’s overall allowance of no more than 5% of interim responses for the universe of written inquiries. |
| C.5.4.7.2 Participation in Meetings and Work Groups |
| 1 |
| The participation requirement is successful when the Contractor is represented at every meeting and workgroup for which attendance is mandatory or requested. |
| C.5.4.8.1 Review and Comment on Draft Change Requests |
| 1 |
| Timely CR review is successful when the Contractor provides comments and the Level of Effort (LOE) assessment and estimate by the closing date and time of the POC Review comment period, which is specified at the beginning of the POC Review period. |
| C.5.4.8.2 Early Involvement |
| 1 |
| Participation in Early Involvement Calls is successful when (1) the Contractor attends all Calls when invited by CMS and/or its SSM, (2) the Contractor has reviewed all documentation prior to the Call, and submitted their questions (3) the Contractor is represented by at least one subject matter expert (SME). |
| C.5.4.8.3.1 Walkthroughs |
| 1 |
| Participation in walkthroughs is successful when (1) the Contractor attends all walkthroughs when invited by CMS and/or its SSM, (2) the Contractor has reviewed all documentation prior to the walkthrough, and (3) the Contractor is represented by at least one SME. |
| C.5.4.8.4 Participation in Testing Changes to Systems |
| 1 |
| The Contractor completes test plans, test executions, and test analysis in a timely manner. |
| C.5.4.8.4 Participation in Testing Changes to Systems |
| 2 |
| The Contractor promptly reports any issues or problems involving poor support from the VDC to their CMS COR. Issues that may adversely affect Contractor testing performance shall be reported within 24 hours. |
| C.5.4.8.4 Participation in Testing Changes to Systems |
| 3 |
| Errors or production problems that should have been identified through Contractor testing and are within the scope of Contractor testing do not occur in production. |
| C.5.4.8.4 Participation in Testing Changes to Systems |
| 4 |
| All interfaces and data exchanges between the Shared System and ancillary claims processing components operate in production without problems. |
| C.5.4.10 Internal Controls |
| 1 |
| Internal controls are successful when a) no Section I findings are identified by SSAE 18 audit and b) no findings are identified by a CFO audit. |
| C.5.4.10.2 Self- Assessment Process for Internal Controls |
| 1 |
| The CPIC Package is submitted to CMS timely. |
C.5.4.10.2 Self-Assessment Process for Internal Controls
| 2 |
| Internal controls are successful when no material weaknesses are identified in the CPIC Report of Material Weaknesses. |
| C.5.4.10.3 Correcting Internal Control Deficiencies – Corrective Action Plan Process |
| 1 |
| Initial CAP reports are timely when they are provided within 45 calendar days of receiving a final audit report or after discovery of a material weakness. |
| C.5.4.10.3 Correcting Internal Control Deficiencies – Corrective Action Plan Process |
| 2 |
| Quarterly CAP reports are timely when they are provided within 30 calendar days after the end of each quarter. |
| C.5.4.10.3 Correcting Internal Control Deficiencies – Corrective Action Plan Process |
| 3 |
| The Contractor’s corrective action procedures are successful when its deficiencies have been corrected and validated within one year of being identified. |
C.5.4.10.4 Statement on Standards for Attestation Engagements 18 (SSAE 18)
| 1 |
| Internal controls are successful when no Section I findings are identified in the SSAE 18 audit. |
| C.5.5.1 Process Initial and Revalidation Enrollment Applications (Paper) |
| 1 |
| The Contractor shall process all initial and revalidation CMS-855 Applications in accordance with all of the instructions found in the timeliness standards in Pub. 100-08, Chapter 15. |
| C.5.5.1 Process Initial and Revalidation Enrollment Applications (Paper) |
| 2 |
| We applications described in C.5.5.1 of this SOW will be considered accurately processed when 98 percent of applications are processed in accordance with all of the instructions in IOM Pub.100-08, Chapter 15. |
| C.5.5.1 Process Initial and Revalidation Enrollment Applications (Web-based) |
| 3 |
| The Contractor shall process all initial and revalidation web-based enrollment applications in accordance with all of the instructions found in the timeliness standards in Pub. 100-08, Chapter 15. |
| C.5.5.2 Process Changes, Updates, Reassignments or Corrections |
| 1 |
| Paper applications described in C.5.5.2 of this SOW will be processed in accordance with all the instructions found in the timeliness standards in Pub.100-08, Chapter 15. |
| C.5.5.2 Process Changes, Updates, Reassignments or Corrections |
| 2 |
| Web-based applications described in C.5.5.2 of this SOW shall be processed in accordance with all of the instructions found in the timeliness standards in Pub. 100-08, Chapter 15. |
| C.5.5.2 Process Changes, Updates, Reassignments or Corrections |
| 3 |
| The applications described in C.5.5.2 of this SOW will be considered accurately processed when 98 percent of applications are processed in accordance with all of the instructions in IOM Pub. 100-08, with the exception of the timeliness standards identified in C.5.5.2. |
| C.5.5.3 Revocations/ Deactivations |
| 1 |
| The Contractor shall process 100 percent of all revocation actions in accordance with the revocation instructions in IOM Pub. 100-08. |
| C.5.5.3 Revocations/ Deactivations |
| 2 |
| The Contractor shall deactivate Medicare billing privileges in accordance with the deactivation instructions in IOM Pub. 100-08. |
| C.5.5.4 Provider Enrollment Appeals |
| 1 |
| The Contractor shall process 100 percent of all provider enrollment appeals in full accordance with all appeals instructions in IOM Pub. 100-08. |
| C.5.7.1 Provider Outreach and Education |
| 1 |
| The Contractor will achieve an error rate equal to or lower than the current Government Performance Results Act (GPRA) goal. The goal for each year is published in the Report on Improper Medicare Fee-for-Service Payments. For contractors who exceed this goal, CMS reserves the right to require additional reporting related to the way they use outreach and education to achieve a reduction. Contractors whose error rate is equal to or greater than 25% higher than the GPRA goal may be required to provide quarterly updates to CMS on their efforts to use education to reduce their error rate. Contractors whose error rate is equal to or greater than 50% higher than the current GPRA goal may be required to provide monthly updates to CMS on their efforts to use education to reduce their error rate. The need for quarterly and monthly updates will be re-evaluated after a CERT report is published. |
| C.5.7.2.1 Telephone Inquiries-QCM |
| 1 |
| Of all telephone calls monitored for the quarter, the percentage of calls scoring as “ “Achieves Expectations” or higher for Knowledge Skills and Customer Skills and scoring as “Pass” for Adherence to Privacy Act using the Quality Call Monitoring tool shall be no less than 95% (cumulative for the quarter). |
| C.5.7.2.1 Telephone Inquiries-Call Completion Rate |
| 2 |
| The provider contact center shall complete at least 95% of incoming calls on an IVR-only line, 80% of incoming calls on a CSR-only line, and 80% of incoming calls on an IVR/CSR combined line as measured on a quarterly basis. |
| C.5.7.2.1 Telephone Inquiries-Average Speed of Answer |
| 3 |
| The provider contact center shall maintain an average speed of answer 60 seconds or less when measured on a quarterly basis. |
| C.5.7.2.2 Written Inquiry Responses-QWCM |
| 4 |
| Of all written responses monitored for the quarter,( including Provider Research Specialists {PRRS} responses), the percentage of written inquiry responses scoring as “Achieves Expectations” or higher for Knowledge Skills and Customer Skills and scoring as “Pass” for Adherence to Privacy Act using the Quality Written Correspondence Monitoring tool shall be no less than 95% (cumulative for the quarter). |
| C.5.7.2.2 Written Inquiry Responses- Timeliness |
| 5 |
| All 100% written provider general and provider PRRS inquiries shall be responded to within 45 business days of receipt with either a final response or an interim response; and no more than 5% of the universe of written responses to provider inquiries shall be interim responses. |
| C.5.7.2.3 Provider Relations Research Specialists(PRRS) Responses-Timeliness |
| 6 |
| At least 75% of complex provider inquiries referred to the Provider Relations Research Specialists (PRRS) by provider telephone CSRs shall be answered within 25 business days of receipt. |
| C.5.7.3.2 Website Satisfaction Score |
| 7 |
| The Contractor maintains, during the evaluation period, an average website satisfaction score of at least 64 on the website satisfaction survey supplied by CMS. This average score is derived from the average website satisfaction score reported for the contractor on the Foresee web portal of the last day of every full month within the evaluation period. Each of these “last day” scores uses ForeSee’s score with impacts” setting and is based on 300 immediately preceding completed surveys. In computing average scores, if the computation ends in .5 or higher, the average score will round up to the nearest whole number; if the computation ends below .5 the average score will round down to the nearest whole number. NOTE: There must be at least two “last day” scores within the evaluation period for this standard to be considered valid. If two “last day” scores cannot be derived, this standard shall not be used. |
| C.5.7.2.1 Telephone Inquiries -- QAM |
| 8 |
| The Contractor shall achieve an average quality rate of at least 95% for all CSR calls monitored under the Quality Assurance Monitoring tool for the contract year. |
| C.5.8.2 General Claims Processing |
| 1 |
| Claims processing is successful when claims are paid with acceptable accuracy as evidenced by a contractor-specific Comprehensive Error Rate Testing (CERT) error rate not to exceed the Government Performance Results Act (GPRA) national paid claims error rate goal for the year (The goal for each year is published in the Report on Improper Medicare Fee-for-Service Payments. http://www.cms.gov/cert). |
| C.5.8.2 General Claims Processing |
| 2 |
| Clean claims are processed timely when 95% of the Part A and Part B of A claims processed in the FISS are processed within the claims payment floor and ceiling specified in IOM Pub. 100-04, Chapter 1, §80.2.1.1 and §80.2.1.2. The contractor must meet this standard on a monthly basis. |
| C.5.8.2 General Claims Processing |
| 3 |
| Clean claims are processed timely when 95% of the Part B claims processed in the MCS are processed within the claims payment floor and ceiling specified in IOM Pub. 100-04, Chapter 1, §80.2.1.1 and §80.2.1.2. The contractor must meet this standard on a monthly basis. |
| C.5.8.2 General Claims Processing |
| 4 |
| Other-Than-Clean claims are processed timely when 100% of the claims are processed within 45 days of the receipt (IOM Pub. 100-04, Chapter 1, §80.3.3). The contractor must meet this standard on a monthly basis. |
| C.5.8.2.1 Communication Of Claims Processing Problems |
| 1 |
| Communication is timely when CMS receives notification within five (5) business days of (Contractor) discovering systematic and/or operational claims processing problems that do not cause disruption of claims processing payments. |
| C.5.8.2.1 Communication Of Claims Processing Problems |
| 2 |
| Communication is timely when CMS receives notification within 24 hours or within the same business day of identification, if the problem may cause disruption of benefit payments beyond a single provider. |
| C.5.8.2.2 Resolution of Common Working File (CWF) rejected claims involving another Medicare Administrative Contractor (MAC) |
| 1 |
| Claims prevented from processing correctly because another MAC posted a prior bill to CWF are resolved correctly in accordance with the instructions in IOM Pub.100-04, Chapter 27, sections 50-50.3 and the CWF system documentation. |
| C.5.8.2.2 Resolution of Common Working File (CWF) rejected claims involving another Medicare Administrative Contractor (MAC) |
| 2 |
| Bills unable to be processed because another MAC posted a prior bill to CWF are handled correctly when the two contractors work together to resolve the error. If only one MAC is involved, the MAC shall resolve the problem internally. |
| C.5.8.2.4.2 Identification of Potential MSP Existence |
| 1 |
| Contractor identifies all claims or situations in accordance with IOM Pub. 100-4, Chapter 1, section 70 and IOM Pub. 100-05, Chapter 3. |
| C.5.8.2.4.2 Identification of Potential MSP Existence |
| 2 |
| Contractor identifies all claims or situations in accordance with IOM Pub. 100-5, IOM Pub. 100-05, Chapter 4, §10.3, and Chapter 5, §10.1, §10.2, and §10.7. |
| C.5.8.4.3 Generate And Mail Claims Processing Documents |
| 1 |
| MSN management is successful when the Contractor accurately generates and mails 98% of MSNs in accordance with IOM Pub. 100-04, Chapter 21. |
| C.5.8.4.3 Generate And Mail Claims Processing Documents |
| 2 |
| Document management is successful when the Contractor mails all required documents that are not being transmitted electronically. COB/MediGap files must be transferred to the COB electronically even if the initial claims were submitted on paper. |
| C.5.8.7.1 Listing Of Competitive Acquisition Program Participating Physicians And Practitioners |
| 1 |
| The Contractor’s performance of the CAP physician election process is successful when it conforms to the activities and timeframes required in CRs 4044, 4064, 4306, 4309, 4404 and subsequent CRs 5079, 5207, 5259, 5332, and 5579. |
| C.5.8.7.2 Monitoring Competitive Acquisition Program Physicians And Practitioner Claims For Administering Part B Drugs |
| 1 |
| The Contractor’s monitoring of CAP physicians and practitioners claims for administering drugs is successful when the Contractor adjudicates CAP claims in accordance with IOM Pub. 100-04 Chapters 17 and 21 (CR 4044, 4064, 4306, and 4309, 4404 and subsequent CRs 5079, 5207, 5259, 5332, and 5579). |
| C.5.9.1 Reopening |
| 1 |
| Where appropriate, the Contractors shall reopen an initial determination or a redetermination to review a decision in accordance with 42 Code of Federal Regulations (CFR) 405.980 and Internet Only Manual (IOM) 100-4, Chapter 34. |
| C.5.9.2 Establishing Good Cause for Reopening Initial Determinations and Redeterminations |
| 2 |
| The Contractor shall establish good cause for reopening a determination or decision in accordance with 42 CFR 405.986. |
| C.5.9.3 Reopening Decisions |
| 3 |
| The Contractor shall issue its revised determination or decision to the parties to the initial determinations or redeterminations in accordance with 42 CFR 405.982. |
| C.5.10.1 Redetermination Requests |
| 1 |
| The Contractor shall process requests for redetermination of Medicare initial claims determinations in accordance with 42 CFR 405.940-958 and IOM 100-4, Chapter 29, section 310. |
| C.5.10.1.1 Controlling Receipt Of Correspondence |
| 2 |
| The Contractor shall control and track redetermination requests upon receipt in the mailroom. |
| C.5.10.1.2 Document Imaging and Indexing |
| 3 |
| The Contractor shall electronically image and index all redetermination correspondence upon receipt in the corporate mailroom, and if applicable, secure Internet portal or fax. All redetermination requests include documentation and incoming correspondence supplied in support of the request, shall be scanned/imaged. |
| C.5.10.1.3 Acceptance of Valid Redetermination Requests |
| 4 |
| The Contractor shall accept valid written redetermination requests filed by a party to an initial determination in the form and manner prescribed in regulation and at 42 CFR 405. 944. |
If the Contractor is in the process of recouping an identified overpayment and an appeal request is received regarding the overpayment recoupment action, the overpayment area must be notified to stop recoupment efforts pending a decision on the appeal. Refer to Medicare Modernization Act (MMA) Section 935(f) (2).
C.5.10.1.3.1 Confirmation of Receipt of Redetermination Requests
| 5 |
| The Contractor shall provide a mechanism for providers and suppliers to obtain confirmation of the receipt of their redetermination requests. This confirmation status shall be made available within 10 calendar days of the date of receipt of the redetermination request by the Contractor. Refer to Statement of Work section C.5.10.1.3.1 for additional details. |
| C.5.10.1.4 Misfiled Appeal Requests |
| 6 |
| Within 60 calendar days of receipt, the Contractor shall timely forward misfiled appeal requests to the appropriate adjudicating entity. (MAC, QIC, Administrative Law Judge, etc.) Refer to IOM 100-4, Chapter 29, section 310.1 |
| C.5.10.1.5 Granting of Extensions for Late Redetermination Requests and Determination of Good Cause |
| 7 |
| In accordance with 42 CFR 405.942, the Contractor may extend the timeframe for filing a request for redetermination if the party demonstrates good cause for missing the deadline to request a redetermination. |
| C.5.10.1.7 Withdrawals and Eligibility-Based Dismissals |
| 8 |
| When appropriate, the Contractor shall dismiss a request for redetermination and provide a written notice of the dismissal in a timely manner. |
| C.5.10.1.8 Assistance to Beneficiary |
| 9 |
| The Contractor shall assist the beneficiary in obtaining from the provider any additional information needed to process and complete the redetermination. Refer to IOM 100-4, Chapter 29 section 310.4(D) (3). |
The Contractor shall clearly annotate the redetermination case file with any requests for additional documentation made on behalf of the beneficiary.
| C.5.10.1.9 Conduct And Notice Of The Redetermination |
| 10 |
| Contractors shall prepare notice of the redetermination in accordance with 42 CFR 405.956 and IOM 100-4, Chapter 29, section 310. |
Contractors shall process and mail all redeterminations within 60 calendar days of the date the Contractor receives a timely filed request for redetermination. When a party submits additional evidence after filing the request for redetermination, the Contractor’s 60 day decision-making timeframe is extended by 14 calendar days for each submission. Please refer to IOM 100-4, Chapter 29, and section 310.4.
The decision making timeframe is also extended if the Contractor grants an appellant’s request for an extension of the 120 day filing deadline in accordance with 42 CFR 405.942(b). Also see IOM 100-4, Chapter 29, section 310.2.
When determining whether a misfiled appeal request was processed timely within 60 calendar days by the appropriate Contractor jurisdiction, the appropriate Contractor shall use the date the misfiled request was received in the appropriate Contractor’s corporate mailroom.
C.5.10.2 Appeal Decision Effectuation
| 1 |
| The Contractor shall take all necessary payment actions on all levels of appeal (redeterminations, reconsiderations, ALJ decisions, Medicare Appeals Council reviews, and decisions issued in the federal district court). Payment should be made timely, and in accordance with instructions in IOM, 100-4, Chapter 29. |
| C.5.10.3 Monthly Statistical Report on Reopening’s and Appeals Activities |
| 1 |
| The Contractor shall prepare and submit to CMS a report summarizing monthly appeals activity in accordance with IOM Pub.100-6, Chapter 6, section 640. The Contractor shall report non-clerical error reopening in the CMS 2590/2591 reports in accordance with IOM Pub.100-6, Chapter 6, sections 90, 100.6, 350 and 360.4. |
| C.5.11.1 Use Of Trust Fund |
| 1 |
| The Contractor’s use of trust fund dollars is successful when it will not cause CMS to be cited for financial management related deficiencies on the CMS annual CFO audit. |
| C.5.11.1.1 Certification Of Financial Reporting By Chief Financial Officer For Medicare Operations |
| 1 |
| Financial reports are submitted and certified within the required timeframes in IOM Pub. 100-06, Chapter 5. |
| C.5.11.1.3 Resolution Of Financial Deficiencies |
| 1 |
| Initial CAP reports are timely when they are provided within 45 calendar days of receiving a final audit report. |
| C.5.11.1.3 Resolution Of Financial Deficiencies |
| 2 |
| Quarterly CAP reports are timely when they are provided within 30 calendar days after the end of each quarter. |
| C.5.11.1.3 Resolution Of Financial Deficiencies |
| 3 |
| The Contractor’s corrective action procedures are successful when its deficiencies have been corrected and validated within one year of being identified. |
| C.5.11.2.2 Benefits Account |
| 1 |
| The benefits account is maintained successfully when it is timely reconciled with the bank statement in accordance with IOM Pub. 100-06, Chapter 5, §70-§90.7, §500-§500.6 and §510-§510.9. |
| C.5.11.2.3 Account Reconciliation/ Contractor Monthly Bank Reconciliation Worksheet (CMBRW) |
| 1 |
| The Contractor’s CMBRW is successful when the bank account reconciles accurately. |
| C.5.11.2.3.1 Cash Collection Worksheet |
| 1 |
| The Contractor’s cash collection worksheet is successful when the deposits, interest offsets and HI/SMI percentage splits are computed and recorded on financials accurately. |
| C.5.11.2.3.2 Estimated Allowance for Uncollectible Accounts |
| 1 |
| The Contractor’s allowance matrix is successful when the allowance calculation is computed and recorded on financials accurately. |
| C.5.11.3.2.1 Cost Report Acceptance |
| 1 |
| Cost report acceptance is timely if it is completed within 30 days from the receipt date of the provider’s cost report. |
| C.5.11.3.2.1 Cost Report Acceptance |
| 2 |
| Cost report reminder letters are timely when a CMS review indicates that they are performed in accordance with IOM Pub. 100-06, Chapter 8, §10.3.1. |
| C.5.11.3.2.1 Cost Report Acceptance |
| 3 |
| Suspension/reduction of a provider’s payments due to untimely filing of a cost report is accurate when a CMS review indicates they are performed in accordance with IOM Pub. 100-06, Chapter 8, §10.2. |
| C.5.11.3.2.1 Cost Report Acceptance |
| 4 |
| Suspension/reduction of a provider’s payments due to a rejected cost report is accurate when a CMS review indicates they are performed in accordance with IOM Pub. 100-06, Chapter 8, §10.2. |
| C.5.11.3.2.2 Tentative Settlements |
| 1 |
| Tentative settlements are timely when they are completed within 60 days of the acceptance of the provider’s cost report |
| C.5.11.3.2.2 Tentative Settlements |
| 2 |
| Tentative settlements are accurate when a CMS review indicates that they are performed in accordance with IOM Pub. 100-06, Chapter 8, §10.5. |
| C.5.11.3.2.2 Tentative Settlements |
| 3 |
| Cost to Charge Ratios are calculated accurately when a CMS review indicates that they are in compliance with IOM Pub. 100-04, Chapter 3, §20.1.2.1, 140.26, 150.24 and 190.7.2.2, IOM Pub. 100-04, Chapter 4, §10.7.2, and IOM Pub. 100-06, Chapter 8, §10.5. |
| C.5.11.3.2.3.2 Desk Reviews |
| 1 |
| A provider’s permanent file is considered properly maintained when a CMS review indicates that it is maintained in accordance with CMS Pub- 100-06, Chapter 100, § 130. |
| C.5.11.3.2.5.3 Audits of Home Office Cost Statements |
| 1 |
| Audited home office cost statements are properly distributed to servicing contractors if the designated home office contractor accurately distributes the audited home office cost statement and audit adjustments to all servicing contractors at the completion of the audit in accordance with IOM Pub. 100-06, Chapter 8, §120.5 |
| C.5.11.3.2.6 Final Settlement |
| 1 |
| Cost reports that do not require an audit are settled timely when the NPR is issued within 12 months of the acceptance of a cost report. |
| C.5.11.3.2.6 Final Settlement |
| 2 |
| Cost reports are settled accurately when CMS review determines compliance with Medicare payment policy as defined in the Medicare Provider Reimbursement Manuals. |
| C.5.11.3.2.6 Final Settlement |
| 3 |
| Cost reports that are audited shall have an NPR and final adjustment report issued within 60 days of the exit conference or 60 days after the adjustments are finalized if the exit conference is waived |
| C.5.11.3.2.6 Final Settlement |
| 4 |
| Outlier reconciliations are considered accurate when a CMS review indicates that they are in compliance with IOM Pub. 100-04, Chapter 3, §20.1.2.5, 140.2.4.4, 150.26 and 190.7.2.3, and IOM Pub. 100-04, Chapter 4, §10.7.2.4. |
| C.5.11.3.2.7.1 Cost Report Reopenings |
| 1 |
| Revised NPRs are timely when they are issued within 180 days of receipt of all information and documentation necessary to resolve the reopening issue. |
| C.5.11.3.2.7.1 Cost Report Reopenings |
| 2 |
| Revised NPRs are accurate when a CMS review determines compliance with IOM Pub. 100-06, Chapter 8, §100. |
| C.5.11.3.2.7.1 Cost Report Reopenings |
| 3 |
| Notices or denials of cost report reopenings are accurate when a CMS review determines compliance with IOM Pub. 100-06, Chapter 8, §100. |
| C.5.11.3.2.7.1 Cost Report Reopenings |
| 4 |
| Cost report reopenings are accurate when CMS review determines compliance with Medicare payment policy as defined in the Medicare Provider Reimbursement Manuals. |
| C.5.11.3.2.8.2 PRRB Appeals |
| 1 |
| Provider Reimbursement Review Board (PRRB) cases resolved by mediation or administrative resolution are considered accurate when A CMS review indicates the issues are resolved in accordance with Medicare reimbursement principles. |
| C.5.11.3.3.2 Provider-Specific File Correctness |
| 1 |
| Data in the PSF is considered accurate when a CMS review indicates that it is in compliance with IOM Pub. 100-04, Chapter 3, §20.2.3.1 and the file layout in Addendum A of IOM Pub. 100-04, Chapter 3. |
| C.5.11.3.3.6 Exception Requests: Tax Equity And Fiscal Responsibility Act |
| 1 |
| Target Limits are timely when applications are processed to completion within 75 days after receipt by the Contractor or returned to the hospital as incomplete within 60 days of receipt. |
| C.5.11.3.3.6 Exception Requests: Tax Equity And Fiscal Responsibility Act |
| 2 |
| Target Limits are accurate when they comply with TEFRA payment policy. |
| C.5.11.3.4.2 System For Tracking Audit And Reimbursement System |
| 1 |
| STAR database is maintained accurately and timely when a CMS review indicates that it is in compliance with the STAR manual. |
| C.5.11.4 Non-Medicare Secondary Payer Overpayment |
| 1 |
| The contractor overpayment procedures on Providers, Physicians, other suppliers and Beneficiaries are successful when the recovery activities and process is accurate and timely in accordance with IOM Pub 100-6, Chapters 3 and 4. |
C.5.11.4.2 Applications for Extended Repayment Schedule
| 1 |
| The Contractor shall process requests for an Extended Repayment Schedule (ERS) for provider, physician, and other suppliers’ overpayments in accordance with IOM Pub. 100-06, Chapter 4. The Contractor shall process requests for an ERS for beneficiary overpayments in accordance with IOM Pub. 100-06, Chapter 3 . Contractor is successful when ERS reports are timely submitted on a quarterly basis to the Regional Office with the required data. |
| C.5.11.4.3 Limitation on Recoupment (935) for Providers, Physicians and other Suppliers overpayments |
| 1 |
| The Medicare contractor’s process regarding Limitation on Recoupment is successful when the contractor will cease recoupment or not begin recoupment at the normally scheduled time (41 days for 1st level appeal and 76 days for 2nd level appeal) for an eligible appeal and the contractor calculates 935 interest timely and accurately, if the debtor prevails at the ALJ or higher level. |
| C.5.11.5 Non-Medicare Secondary Payer Debt Collection |
| 1 |
| The Contractor shall collect all debts in accordance with the Federal Claims Collection Act and IOM Pub. 100-06, Chapters 3 and 4. |
| C.5.11.5 Non-Medicare Secondary Payer Debt Collection |
| 2 |
| The contractors are required to process overpayment data resulting from OIG audits and make the necessary recoveries within a reasonable timeframe in accordance to IOM Pub.100-06 Chapters 3 and 4. In addition, the contractors are required to report back to CMS Central Office the cumulative dollar amount of the recoveries up to four times per year and if required to do so, perform a reconciliation between the dollar amount recovered and the dollar amount requested to be recovered. |
| C.5.11.6 Non-Medicare Secondary Payer Debt Referral |
| 1 |
| The Contractor’s debt referral procedures are successful when its eligible delinquent debt has been referred by the 180th day of delinquency in accordance with the IOM Pub 100-6, chapter 4, Section 70. |
| C.5.11.6 Non-Medicare Secondary Payer Debt Referral |
| 2 |
| The contractor is successful when debtor disputed requests are responded to on or before 30 days after the date of receipt in accordance with the IOM Pub 100-06, chapter 4, Section 70. |
| C.5.11.6.1 Non-Medicare Secondary Payer DCIA Intent to Refer Letter |
| 1 |
| The contractor is successful when intent to refer letters are issued on or before the debt is 90 days delinquent in accordance with the IOM Pub 100-06, chapter 4, Section 70. |
| C.5.11.6.1 Non-Medicare Secondary Payer DCIA Intent to Refer Letter |
| 2 |
| The contractor is successful when intent to refer letters are returned and researched for a better address has been completed or before the 10 days after the date of receipt in accordance with the IOM Pub 100-06, chapter 4, Section 70. |
| C.5.11.6.3 Debt Collection System Database |
| 1 |
| The contractor is successful when the DCS is updated timely for changes to status and balance, as appropriate, in accordance with the IOM Pub 100-06, chapter 4, Section 70. |
| C.5.11.6.4 Posting of Debts Collected by Treasury |
| 1 |
| The contractor is successful when Treasury collections are posted timely and accurately and the Collection/Refund Spreadsheet is completed and returned to CMS within 15 days after receipt in accordance with IOM Pub 100-06, chapter 4 Section 70. |
| C.5.11.6.4 Posting of Debts Collected by Treasury |
| 2 |
| The contractor is successful when Treasury collections refunds are posted timely and accurately and the Collection/Refund Spreadsheet is completed for any refunds due and returned to CMS within 30 days after the date of receipt. |
| C.5.11.6.5 Posting of Debts Returned to Agency (RTA) by Treasury |
| 1 |
| The contractor is successful when debts on the RTA are researched to determine that the resolution recommended by the Department of the Treasury is accurate and the RTA report is reconciled and returned to CMS within 30 days after receipt. |
| C.5.11.9.2 Financial Reporting Audits/Reviews |
| 1 |
| Initial CAP reports are timely when they are provided within 45 calendar days of receiving a final audit report or after discovery of a material weakness. |
| C.5.11.9.2 Financial Reporting Audits/Reviews |
| 2 |
| Quarterly CAP reports are timely when they are provided within 30 calendar days after the end of each quarter. |
| C.5.11.9.2 Financial Reporting Audits/Reviews |
| 3 |
| The Contractor’s corrective action procedures are successful when its deficiencies have been corrected within one year of being identified. |
| C.5.11.10 Medicare Credit Balance report activities |
| 1 |
| The Contractor shall monitor and ensure provider compliance with the credit balance reporting process. Ensure that providers submit properly completed CMS-838 reports on time, claims adjustments to Medicare credit balances are properly made, payments to providers are suspended for untimely submission of CMS-838 reports, demand letters are appropriately issued to providers that have not repaid their Medicare credit balances, and outstanding Medicare credit balances are included in Medicare financial reports. |
| C.5.12 Medical Review |
| 1 |
| Medical Review is successful when claims are paid with acceptable accuracy as evidenced by a contractor-specific Comprehensive Error Rate Testing (CERT) error rate not to exceed the Government Performance Results Act (GPRA) national paid claims error rate goal for the year (The goal for each year is published in the Report on Improper Medicare Fee-for-Service Payments. http://www.cms.gov/cert). |
| C.5.12.1 Development Of Improper Payment Reduction Strategy |
| 1 |
| The Contractor’s Improper Payment Reduction Strategy (IPRS) is successful when problems targeted in the strategy are addressed during the contract year using the progressive corrective action (PCA) process and the Contractor can demonstrate a change in billing behavior. |
C.5.12.1 Development Of Improper Payment Reduction Strategy
| 2 |
| The Contractor is successful when actions identified in the IPRS are implemented as reflected in the Strategy Analysis Report (SAR) and the following year’s IPRS. |
C.5.12.1 Development Of Improper Payment Reduction Strategy
| 3 |
| For each problem identified in the IPRS, the SAR shall address in detail interventions and outcomes, and for new problems shall propose detailed interventions. |
C.5.12.1 Development Of Improper Payment Reduction Strategy
| 4 |
| The Contractor is successful when there is evidence they considered “major findings” identified on the Recovery Audit Contractor website in the MAC’s jurisdiction 100% of the time when prioritizing their IPRS. (A major finding refers to a service specific finding on an issue that the Recovery Audit Contractors have reviewed that has resulted in a significant improper payment and has proven to be a vulnerability to the Medicare Trust Fund.) |
| C.5.12.1.5 Medical Review of Claims |
| 1 |
| The Contractor is successful when there is timely completion of Medical Review adjudication per CMS policy. |
| C.5.12.1.5 Medical Review of Claims |
| 2 |
| The Contractor is successful when there is 95% accuracy in adjudication of claims, based on Quality Assurance Inter-reviewer reliability testing and accuracy reviews. |
| C.5.12.2.14 Data Analysis |
| 1 |
| The Contractor is successful when MR related billing errors concerning coverage and coding made by providers are identified through data analysis. |
| C.5.12.2.14 Data Analysis |
| 2 |
| The Contractor is successful when appropriate referrals are made based on data analysis to Provider, Outreach & Education (POE), BI unit, Recovery Audit Contractors, and other entities. |
| C.5.14.1 Implementation of Medicare Secondary Payer Operations |
| 1 |
| Contractor’s MSP operation is in accordance with IOM Pub. 100-5, Chapter 2. |
| C.5.14.2 Electronic Correspondence Referral System Status Inquiries |
| 1 |
| Status inquiries are performed in accordance with IOM Pub.100-5, Chapter 5, §10.2 and 10.5. |
| C.5.14.3.1 Medicare Secondary Payers Claims payment determinations |
| 1 |
| Contractors make accurate MSP claims payment determination to ensure that Medicare pays only for services for which it is responsible in accordance to 100-05, Chapter 1, §40-70. |
| C.5.14.3.1 Medicare Secondary Payers Claims payment determinations |
| 2 |
| Contractors make accurate MSP claims payment determination to ensure that Medicare pays only for services for which it is responsible in accordance to 100-05, Chapter 2, §10-60. |
| C.5.14.3.2 Medicare Secondary Payer Claims Adjudication and Validation |
| 1 |
| Contractor identifies all claims or situations in accordance with IOM Pub. 100-5, Chapter 1, § 30 and Chapter 5, §30-50. |
| C.5.14.3.3 MSP Claims Inquiries |
| 1 |
| The Contractor shall respond to inquiries and correspondence from insurers and other interested parties (e.g., attorneys and/or beneficiaries, etc.) on MSP billing requirements to assist with resolving claims inquiries accurately, timely, and responsively in accordance with IOM Pub. 100-05, Chapter 5, Section 10 and IOM Pub. 100-09, Chapter 6, Section 60. |
Contractors are expected to meet a 95% accuracy and timeliness Standard.
Note: Responses can include adjustments, offsets and redeterminations.
| C.5.14.3.4 MSP Claim with Complete EOB: Update CWF |
| 1 |
| The Contractor shall identify all claims or situations and accurately add an “I” record in accordance with IOM Pub. 100-5, Chapter 5, Sections 10 and 20 and Chapter 6, Sections 10 and 20. |
Contractors are expected to meet a 95% accuracy and timeliness
Note: Typos will not be allowed in the following critical fields for “I” records or all ECRS requests: HICN, MSP Type, MSP Effective Date, Patient Relationship, and Insurer Name.
| C.5.14.3.5 Incomplete EOB: Possible MSP Claim, Possible MSP Situation, or CWF Exclusion: Forward to BCRC |
| 1 |
| All MSP claims information shall be forwarded to the BCRC in accordance with IOM Pub. 100-5, Chapter 4, Sections 10, 20, 30.3.2, and 40.0.3 and Chapter 5 Sections 10.1, 10.2 and 10.7. |
Contractors are expected to meet a 95% accuracy and timeliness
Note: Typos will not be allowed in the following critical fields for “I” records or all ECRS requests: HICN, MSP Type, MSP Effective Date, Patient Relationship, and Insurer Name.
| C.5.14.4 Transfer of Documentation and Phone Calls to the Benefits Coordination and Recovery Center |
| 1 |
| The Contractor shall transfer to the BCRC documentation and telephone calls in accordance with IOM Pub. 100-05, Chapter 5, §10.2, 10.3 and 10.6. |
| C.5.14.5 Medicare Secondary Payer Hospital Audits |
| 1 |
| Hospital audits and reviews are performed in accordance with IOM Pub. 100-5, Chapter 3, sections 20 and 30, and Chapter 5, section 70 (including associated exhibits, 70.5.1–70.5.4). |
| C.5.14.6.1 Duplicate Primary Payments |
| 1 |
| Solicited refunds adjudication is successful when all checks are posted to established debts (means A/R already established and an associated record on CWF) within 20 calendar days from the check’s date of deposit. |
Contractors are expected to meet a 95% accuracy and timeliness standard.
| C.5.14.6.1 Duplicate Primary Payments |
| 2 |
| Voluntary/unsolicited refunds are successful when checks that do not have an associated debt (not on ECRS), thus requiring further development , are referred to the Benefits Coordination and Recovery Center (BCRC) via ECRS within 20 calendar days from the check’s date of deposit. |
| C.5.14.6.1 Duplicate Primary Payments |
| 3 |
| Voluntary/unsolicited refund adjudication is successful when checks, where no ECRS is needed BUT no A/R has been established, are posted to the debt within 60 calendar days from the check’s date of deposit. |
| C.5.14.6.1 Duplicate Primary Payments |
| 4 |
| DPPs are successfully addressed when demands for repayment are made and collection efforts initiated within 45 days of receiving notice of a DPP situation. |
| C.5.14.6.2 Inquiries Specific to Debt Collection Efforts for Providers, Physicians and other Suppliers |
| 1 |
| Inquiries specific to debt collection efforts are successful when 95% of all provider, physician and other supplier MSP inquiries shall be acknowledged or responded to within 45 days of receipt, absent IOM instructions to the contrary. |
| C.5.14.6.3 Debt Collection Referral Activities for Providers, Physicians and other Suppliers |
| 1 |
| All checks are adjudicated and posted to established debts or newly identified debts (after a successful ECR’s update/return) within 20 calendar days from the check’s date of deposit. |
Contractors are expected to meet a 95% accuracy and timeliness standard.
| C.5.14.6.3 Debt Collection Referral Activities for Providers, Physicians and other Suppliers |
| 2 |
| All eligible delinquent debts are referred to Treasury for cross-servicing prior to or by the time the debt is 180 days delinquent. |
Contractors are expected to meet a 95% accuracy and timeliness standard.
| C.5.14.6.3 Debt Collection Referral Activities for Providers, Physicians and other Suppliers |
| 3 |
| Debts that are part of or subject to a bankruptcy proceeding are identified and, if at Treasury, recalled and reported properly prior to the end of the current financial reporting period. |
| C.5.14.6.4 MSP Savings Report |
| 1 |
| MSP Savings reports are submitted within the CROWD system in the required timeframes as outlined in IOM Pub. 100-05. |
C.5.14.6.5 Misrouted Benefits Coordination and Recovery Center (BCRC) MSP Recovery Checks (Non-GHP checks) and/or Misrouted Commercial Repayment Center Checks (GHP checks)
| 1 |
| The Contractor shall issue a new check and forward all check copies and correspondence to either the Benefits Coordination and Recovery Center (BCRC) (non-GHP debts/checks) or the CRC (GHP debts/checks) within twenty (20) business days of the original check deposit. |
C.5.14.6.6 Misrouted Benefits Coordination and Recovery Center (BCRC) MSP Recovery Correspondence (Non-GHP) and/or Misrouted Commercial Repayment Center MSP Recovery Correspondence (GHP)
| 1 |
| The Contractor shall transfer all misrouted MSP correspondence (except correspondence related to provider, physician or supplier recovery) to either the BCRC (non-GHP correspondence only) or the CRC (GHP correspondence only) within twenty (20) business days of receipt. |
| C.5.18.1 Education Materials (Rural Health Clinics) |
| 1 |
| The contractor is successful when educational materials are submitted to the COR at least six (6) weeks before their intended use. |
| C.5.19.1 Education Materials (FQHCs) |
| 1 |
| The contractor is successful when educational materials are submitted to the COR at least six (6) weeks before their intended use. |
| C.6.1 Successful Collaboration with Entities Requiring Joint Operating Agreements |
| 1 |
| The execution of a JOA is successful when all parties to the JOA have signed the written agreement. |
| C.6.1 Successful Collaboration with Entities Requiring Joint Operating Agreements |
| 2 |
| The update of a PSC/ZPIC JOA is successful when, for the first year, the JOA is updated quarterly, by January 15th, April 15th, July 15th, and October 15th. After the first year, updates should occur semi-annually, by January 15th and July 15th. |
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