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Attachment J.5 Government Systems Provided for Use
RFP # 75FCMC19R0023
| Government System Name |
| Government System Description |
| Related SOW Major Section Number |
| Related Major Section Name |
| # of Days After Award System Can Be Provided To Contractor |
| CMS Responsible Component |
| Centers for Medicare & Medicaid Services (CMS) Analysis, Reporting and Tracking System (ART) System |
| The CMS system of record for tracking Contractor Business Proposals, Cost Reports, Deliverables, and Workload Information for various departments within the agency and contains financial, budget and cost related information which includes but is not limited to: dashboard reports, contract performance reports and FOIA requests. This system is used by CMS staff and various contractors. |
| C.5.23.6 |
| CMS ART |
| To Be Determined |
| CENTER FOR MEDICARE (CM)/MEDICARE CONTRACTOR MANAGEMENT GROUP (MCMG) |
| Centers for Medicare & Medicaid Services (CMS) Private Wide Area Network (CMSnet) |
| CMSnet is used to securely transport Medicare data between CMS and its contractors. |
| C.5.3 |
| Infrastructure Requirements |
| To Be Determined |
| OFFICE OF INFORMATION TECHNOLOGY (OIT) |
| Comprehensive Error Rate Testing (CERT) Confidential Website and CERT Claims Status Website |
| These systems provide access to all CERT related information, the error rate reduction plan data entry system, the CERT claims feedback page, and payment adjustments and appeals reporting systems. |
| C.5 ALL |
except C.5.5 and C.5.14
| All Contract Requirements except Provider Enrollment and Medicare Secondary Payer |
| To Be Determined |
| CENTER FOR MEDICARE (CM) AND OFFICE OF FINANCIAL MANAGEMENT (OFM) |
| Comprehensive Error Rate Testing (CERT) raw data |
| Contractor-specific raw-data used to determine error rates and causes. |
| C.5 ALL |
| All Contract Requirements |
| To Be Determined |
| OFFICE OF FINANCIAL MANAGEMENT (OFM)/PAYMENT ACCURACY & REPORTING GROUP (PARG) |
| Contractor Administrative Budget and Financial Management System (CAFM) |
| Financial management software system that manages contractor reporting activities pertaining to all benefit payments, banking issues, and Chief Financial Officer (CFO) data. (Used only by durable medical equipment (DME) Medicare Administrative Contractors ( MACs) not on the Health Insurance General Ledger and Accounting System (HIGLAS)) |
| C.5.1 and C.5.11 |
| Workload Transition and Financial Management of Trust Fund Dollars |
| To Be Determined |
| OFFICE OF FINANCIAL MANAGEMENT (OFM) |
| Contractor Reporting of Operational and Workload Data System (CROWD) |
| The application provides the Centers for Medicare & Medicaid Services (CMS) with a timely way to monitor each Medicare Contractors’ performance. It contains workload-reporting capabilities that allow the data to be used for estimating budgets, jurisdictional comparisons, defining operational issues and determining regional and national workload trends. |
| C.5.8, C.5.10, C.5.14 and C.5.23.8 |
| Claims Processing; Appeals; Medicare Secondary Payment savings; Provider Incentives; Denials; Limiting Charges; Interest Payments; and Participating Physician reporting. |
| To Be Determined |
| CENTER FOR MEDICARE (CM)/MEDICARE CONTRACTOR MANAGEMENT GROUP (MCMG) |
| Debt Collection System (DCS) |
| DCS is used for referring eligible delinquent debt for cross-servicing. Used to refer debt to Treasury. |
| C.5.11 and C.5.14 |
| Financial Management of Trust Fund Dollars and Medicare Secondary Payer |
| To Be Determined |
| OFFICE OF FINANCIAL MANAGEMENT (OFM)/ACCOUNTING MANAGEMENT GROUP (AMG) |
| Enterprise Electronic Change Information Management Portal (ECHIMP) |
| The ECHIMP is a user-friendly, Web-based Extranet application that was developed by the Centers for Medicare & Medicaid Services’ (CMS’) Division of Change Operations Management (DCOM) to help streamline and automate the Change Management process. ECHIMP provides Change Request (CR) authors with the ability to complete and validate change request forms on-line, provide level of effort estimates, and provides them with a tool to track their CR from draft to finalization. In addition, the system provides reviewers with a Point of Contact (POC) Review Forum, which consolidates the comments received from multiple reviewers for a particular CR into a single, easy to read conversation-based forum. |
| C.5.4.8.1 |
| Review and Comment on Draft Change Requests |
| To Be Determined |
| CENTER FOR MEDICARE (CM) /MEDICARE CONTRACTOR MANAGEMENT GROUP (MCMG)DIVISION OF CHANGE OPERATIONS MANAGEMENT/ (DCOM) |
| Electronic Correspondence Referral System (ECRS) |
| System used by contractors to transmit Coordination of Benefits information and communicate possible Medicare Secondary Payer (MSP) situations to the Benefits Coordination & Recovery Center (BCRC). The system supports all activities related to the development of MSP records and their specific periods of coverage to be reflected on the Common Working File (CWF). BCRC will use ECRS to communicate actions to the contractor. |
| C.5.14 |
| Medicare Secondary Payer (MSP) |
| To Be Determined |
| OFFICE OF FINANCIAL MANAGEMENT (OFM)/FINANCIAL SERVICES GROUP (FSG)/DIVISION OF MSP PROGRAM OPERATIONS (DMSPPO) |
| Fee Schedule--Ambulance Fee Schedule |
| Software integrated into the shared system. This file is produced by the Centers for Medicare & Medicaid Services (CMS) and distributed to the Medicare Administrative Contractors (MACs), shared system maintainers, and data centers, so that ambulance claims submitted by ambulance providers and suppliers can be correctly priced and paid. The contractor will typically receive this file annually with recurring instructions. |
| C.5 ALL |
| All Contract Requirements |
| To Be Determined |
| CENTER FOR MEDICARE (CM)/HOSPITAL AND AMBULATORY POLICY GROUP (HAPG)/DIVISION OF AMBULATORY SERVICES (DAS) |
| Fee Schedule--Clinical Diagnostic Laboratory |
| Software integrated into the shared system. The file is produced by the Centers for Medicare & Medicaid Services (CMS) and distributed to the Medicare Administrative Contractors (MACs), shared systems, and data centers so that laboratory claims with can be correctly priced and paid. The contractor will typically receive this file quarterly with recurring instruction. |
| C.5 ALL |
| All Contract Requirements |
| To Be Determined |
| CENTER FOR MEDICARE(CM)/HOSPITAL AND AMBULATORY POLICY GROUP (HAPG)/DIVISION OF AMBULATORY SERVICES (DAS) |
Fee Schedule--Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Fee Schedule -referred to as Durable Medicare Equipment Fee Schedule (DMEFS) for DME MACs
| Software integrated into the shared system. System that maintains, updates, and disseminates Part B pricing data for services priced under DMEPOS fee schedules. The system generates rates for Level 2 Healthcare Common Procedure Coding System (HCPCS) codes. The system is legislatively mandated. |
| C.5 ALL |
| All Contract Requirements |
| To Be Determined |
| CENTER FOR MEDICARE (CM)/CHRONIC CARE POLICY GROUP (CCPG)/DIVISION OF DMEPOS POLICY (DDP) |
| Fee Schedule--Medicare Physician Fee Schedule Data Base (MPFSDB) Fee Schedules/Abstracts |
| Software integrated into the shared system. These files are produced and distributed by the Centers for Medicare & Medicaid Services (CMS) in order to supply fee and payment policy information on services performed by physicians or practitioners. Carriers receive the entire MPFSDB annually. The file contains the new fees that are effective each year. Thereafter, carriers receive a quarterly update file that contains corrections only. Quarterly files are created and provided for Medicare Administrative Contractors (MACs) if needed. MACs receive subset extract files of the entire file annually via a recurring instruction. |
| C.5 ALL |
| All Contract Requirements |
| To Be Determined |
| CENTER FOR MEDICARE (CM) |
| Flash Report (relating to the Medicare Cost Report) |
| The Centers for Medicare & Medicaid Services (CMS) uses an informal process to expeditiously communicate to contractors, software vendors, and ROs revisions to the Medicare Cost Report (MCR). |
| C.5.11.3 |
| Cost Reporting and Reimbursement Payment Policy |
| To Be Determined |
| OFFICE OF FINANCIAL MANAGEMENT (OFM)FINANCIAL SERVICES GROUP(FSG)/DIVISION OF PROVIDER AUDIT OPERATIONS (DPAO) |
| Fraud Prevention System (FPS) |
| The Centers for Medicare & Medicaid Services (CMS) system that uses predictive analytics to identify troublesome billing patterns and outlier claims for action. |
| C.5.13 |
| Coordination with Unified Program Integrity Contractors (UPICs) |
| To Be Determined |
| CENTER FOR PROGRAM INTEGRITY (CPI)/DATA ANALYTICS AND CONTROL GROUP (DACG) |
| Healthcare Integrated General Ledger Accounting System (HIGLAS) |
| HIGLAS is a single, unified general ledger accounting system that: |
· Supports all Medicare Administrative Contractors (MACs) and central office administration accounting.
· Maintains standard financial processes and data classifications.
· Promotes consistent, standard processes for the Centers for Medicare & Medicaid Services (CMS) and Fee-for-Service (FFS) MACs.
· Produces automated standardized financial statements and reports.
The Contractor must use HIGLAS for Medicare financial management business processes and reporting. HIGLAS is a CMS-furnished application. Contractor users access HIGLAS using a standard Web browser over HyperText Transfer Protocol (HTTP). The firewall at the HIGLAS physical network boundary will allow HTTP traffic to go through, thus enabling the client access. The primary entry point into HIGLAS is the Medicare Data Communications Network (MDCN). The MDCN supports connectivity to HIGLAS. Based on their roles, contractor users can access certain HIGLAS online functions to support their normal job functions.
The Contractor provides PCs meeting CMS-specified requirements for using HIGLAS.
No special operating or service level agreements are required between the contractor and the HIGLAS maintainer.
| C.5.11 |
| Financial Management of Trust Fund Dollars |
| To Be Determined |
| OFFICE OF FINANCIAL MANAGEMENT(OFM) |
| Healthcare Provider Cost Report Information System (HCRIS) |
| Financial management software. HCRIS includes subsystems for the Hospital Cost Report (CMS-2552-96), Skilled Nursing Facility Cost Report (CMS-2540-96), Home Health Agency Cost Report (CMS-1728-94), Renal Facility Cost Report (CMS-265-94), and Hospice Cost Report (CMS-1984-99). |
| C.5.11 |
| Financial Management of Trust Fund Dollars |
| To Be Determined |
| OFFICE OF FINANCIAL MANAGEMENT (OFM)/FINANCIAL SERVICES GROUP (FSG) |
| Healthcare Integrated General Ledger Accounting System (HIPAA) Eligibility Transaction System (HETS) |
| HIPAA-compliant extranet system for Medicare Administrative Contractors (MACs) to use as the source of eligibility data. This is used for eligibility inquiry/response transactions conducted via the MAC Internet-based provider portals. |
| C.5.7.3.5 |
| Provider Internet Portal |
| To Be Determined |
| CENTER FOR MEDICARE (CM)/PROVIDER COMMUNICATIONS GROUP (PCG)/DIVISION OF PROVIDER COMMUNICATIONS TECHNOLOGY (DPCT) |
| Interns and Residents Information System (IRIS) |
| Financial management software. IRIS is used to produce intern and resident data files on diskette for a cost reporting period from each teaching hospital. The diskette is sent along with Medicare cost reports for that cost reporting period to the Medicare Administrative Contractor (MAC). These data files contain information for hospital counts of interns and residents for direct graduate medical education (GME) and indirect medical education (IME). There is a risk that teaching hospitals may over-report intern and resident counts for GME and IME on cost reports. MACs can reduce the impact of these counts by utilizing duplicates detection software on these data files. |
| C.5.11 |
| Financial Management of Trust Fund Dollars |
| To Be Determined |
| OFFICE OF FINANCIAL MANAGEMENT (OFM)/FINANCIAL SERVICES GROUP (FSG) |
| Medicare Appeals System (MAS) |
| MAS is a web-based case management application that provides workflow management, document management and business intelligence capabilities. |
MAS currently supports the appeals processes for the Medicare Fee-for-Service (FFS), Managed Care (MC), and Part D benefit programs.
MAS is currently used by the Part A Medicare Administrative Contractors (MACs) with potential for other lines of business. In addition, MAS is used by Part A, Part B, and the Durable Medical Equipment Qualified Independent Contractor lines of business, as well as the Office of Medicare Hearings and Appeals.
C.5.9 & C.5.10
| Reopenings & Appeals |
| To Be Determined |
| CENTER FOR MEDICARE (CM)/MEDICARE ENROLLEMENT AND APPEALS GROUP (MEAG)/DIVISION OF APPEALS OPERATIONS (DAO) |
| Maintainer-developed test cases and test scripts |
| A controlled outline for the contents and presentation of a Test Case Specification used by the shared system maintainers and the Beta testing contractors. |
| C.5.4.8 |
| Participation in Change Management Process |
By the start of User Acceptance Testing (UAT), depending on the contract award date, and quarterly thereafter by the start of UAT OFFICE OF INFORMATION TECHNOLOGY (OIT)/ APPLICATIONS MANAGEMENT GROUP (AMG)/DIVISION OF SHARED SYSTEMS MANAGEMENT (DSSM)
| Medicare Audit Program |
| This Centers for Medicare & Medicaid Services (CMS)-approved program is used to identify the audit objectives; the issues, transactions, or cost report entries to be audited, reviewed, or verified; the audit steps to be performed; and the tests to be applied. (See Internet-Only Manual (IOM) Pub. 100-6, Chapter 8, section 50.2.) |
| C.5.11 |
| Financial Management of Trust Fund Dollars |
| To Be Determined |
| OFFICE OF FINANCIAL MANAGEMENT (OFM)/FINANCIAL SERVICES GROUP (FSG)/DIVISION OF PROVIDER AUDIT OPERATIONS (DPAO) |
| Medicare Cost Report Desk Review Program |
| The CMS-approved program is used to analyze the provider’s cost report to determine its adequacy, completeness, and accuracy and reasonableness of the data contained therein. (See Internet-Only Manual (IOM) Pub. 100-6, Chapter 8, section 20.) |
| C.5.11 |
| Financial Management of Trust Fund Dollars |
| To Be Determined |
| OFFICE OF FINANCIAL MANAGEMENT/FINANCIAL SERVICES GROUP (FSG)/DIVISION OF PROVIDER AUDIT OPERATIONS (DPAO) |
| Medicare Coverage Database (MCD) |
| Acts as a central point of dissemination for both National and Local Medicare Coverage policies. On the national side, the MCD houses National Coverage Analyses (NCAs), Coding Analyses for Laboratories (CALs), and National Coverage Determinations (NCDs). On the local side, the MCD houses Local Coverage Determinations (LCDs), Local Medical Review Policies (LMRPs, until December 31, 2005), and contractor articles. |
Besides these policies, the MCD contains downloadable indexes and reports.
| C.5.6 |
| Local Coverage Determinations |
| To Be Determined |
| OFFICE OF COMMUNICATIONS (OC); |
CENTER FOR CLINICAL STANDARDS AND QUALITY (CSQ);
OFFICE OF FINANCIAL MANAGEMENT(OFM)
| Medicare Exclusion Database (MED) |
| The Medicare Exclusion Database is a standard format, cumulative exclusion database that contains information on all exclusions and reinstatement actions in Medicare, Medicaid, and other federal health care programs. The Centers for Medicare & Medicaid Services (CMS) receives this information from the Office of Inspector General monthly. Contractors use the information contained in the MED and the General Accounting Office (GAO) Debarment list to: |
· Determine whether a physician/practitioner/provider or other health care supplier who seeks approval as a provider of services in the Medicare/Medicaid programs is eligible to receive payment
· Ensure that sanctioned providers are not being inappropriately paid.
| C.5.13 |
| Coordination with Unified Program Integrity Contractors (UPICs) |
| To Be Determined |
| OFFICE OF FINANCIAL MANAGEMENT (OFM) |
| National Plan and Provider Enumeration System (NPPES) |
| The National Provider Identifier (NPI) will identify health care providers in electronic transactions for which the Secretary has adopted standards. These transactions include claims, eligibility inquiries and responses, claims status inquiries and responses, referrals, and remittance advices. Note: While CMS may provide an extract data to the contractor, it will not provide system access to NPPES. |
| C.5.5 |
| Provider Enrollment |
| To Be Determined |
| CENTER FOR PROGRAM INTEGRITY (CPI)/PROVIDER ENROLLMENT AND OVERSIGHT GROUP (PEOG) |
| Next Generation Desktop (NGD) |
| Desktop application via which Customer Service Representatives (CSRs) in contractors' contact centers respond to beneficiary claims inquiries referred by the Call Center Operations (CCO). Desktop application via which Medicare Administrative Contractors (MACs) accept and track referrals of complex telephone and written inquiries from the CCO. |
| C.5.4.5.3 |
| Responding to Complex Beneficiary Inquiries; |
Feedback
| To Be Determined |
| OFFICE OF COMMUNICATIONS (OC); CALL CENTER OPERATIONS GROUP (CCOG) |
| Provider Contact Center Quality Monitoring Portal (PQM Portal) |
| Portal accessible to appropriate Centers for Medicare & Medicaid Services (CMS) and Medicare Administrative Contractor (MAC) staff to review Quality Assurance Monitoring (QAM) scores, scorecards, issues, rebuttals, and reports. |
| C.5.7 |
| Provider Customer Service Program |
(PCSP)
| To Be Determined |
| CENTER FOR MEDICARE (CM) /PROVIDER COMMUNICATIONS GROUP(PCG)/DIVISION OF CONTRACTOR PROVIDER COMMUNICATIONS (DCPC) |
| Provider Enrollment, Chain and Ownership System (PECOS) |
| CMS system used by contractors that captures Medicare enrollment information. The PECOS database retains enrollment information and transmits enrollment status/information to the claims systems. |
| C.5.5 |
| Provider Enrollment |
| To Be Determined |
| CENTER FOR PROGRAM INTEGRITY (CPI)/PROVIDER ENROLLMENT AND OVERSIGHT GROUP (PEOG) |
| Provider Inquiries Evaluation System (PIES) |
| Tool designed to facilitate Medicare Administrative Contractor (MAC) provider contact center performance reporting. MACs report performance on specified metrics by the 10th of each month. The PIES data provides the framework to assess MAC performance on a consistent basis relative to requirements, as well as to each other on a comparative level. |
| C.5.7 |
| Provider Customer Service Program (PCSP) |
| To Be Determined |
| CENTER FOR MEDICARE (CM)/PROVIDER COMMUNICATIONS GROUP (PCG)/DIVISION OF CONTRACTOR PROVIDER COMMUNICATIONS (DCPC) |
| Provider Statistical and Reimbursement (PS&R) system |
| The PS&R accumulates statistical and reimbursement data related to Medicare claims processed. It is used by the contractor and institutional providers to accumulate key elements of the Medicare cost report used in final settlement. |
| C.5.11 |
| Financial Management of Trust Fund Dollars |
| To Be Determined |
| OFFICE OF FINANCIAL MANAGEMENT (OFM)/FINANCIAL SERVICES GROUP (FSG)/DIVISION OF PROVIDER AUDIT OPERATIONS (DPAO) |
| Quality Call Monitoring (QCM) Database |
| On-line database where Medicare Administrative Contractors (MACs) enter and manage data related to the quality of responses to provider telephone inquiries. The QCM Chart is used to reduce the subjectivity of those reviewing the quality and accuracy of provider telephone responses. The QCM Scorecard is used to review the quality and accuracy of telephone responses to provider inquiries. |
| C.5.7 |
| Provider Customer Service Program (PCSP) |
| To Be Determined |
| CENTER FOR MEDICARE(CM) /PROVIDER COMMUNICATIONS GROUP (PCG)/DIVISION OF CONTRACTOR PROVIDER COMMUNICATIONS (DCPC) |
| Quality Written Correspondence Monitoring (QWCM) Database |
| On-line database where Medicare Administrative Contractors (MACs) enter and manage data related to the quality of written responses to provider inquiries. The QWCM Chart is used to reduce the subjectivity of those reviewing the quality and accuracy of written responses to provider inquiries. The QWCM Scorecard is used to review the quality and accuracy of written responses to provider inquiries. |
| C.5.7 |
| Provider Customer Service Program (PCSP) |
| To Be Determined |
| CENTER FOR MEDICARE (CM) /PROVIDER COMMUNICATIONS GROUP (PCG)/DIVISION OF CONTRACTOR PROVIDER COMMUNICATIONS (DCPC) |
| Shared Systems |
| “Shared systems” (previously known as standard system) means the systems provided by the Centers for Medicare & Medicaid Services (CMS) to Medicare Administrative Contractors (MACs) to process Medicare claims. |
| C.5 ALL |
| All Contract Requirements |
| To Be Determined |
| OFFICE OF INFORMATION TECHNOLOGY (OIT)/ APPLICATIONS MANAGEMENT GROUP (AMG)/DIVISION OF SHARED SYSTEMS MANAGEMENT (DSSM) |
| Shared Systems Module – Combined Common Edits and Enhancements Module (CCEM) |
| Coded and delivered by the Shared System Maintainers (one set of software for Part A and a separate set of software for the Part B processing), CCEM is an editing process that prepares inbound transactions (claims and claim status) for entry into the core adjudication system. The CCEM software installs in the Medicare Administrative Contractors (MAC’s) Local Data Center (LDC). A separate set of CCEM software which processes transactions at the Virtual Data Center (VDC) handles the Receipt and Control processes. The CCEM Receipt and Control modules handle the outbound transaction(s) processing in order to send data to the LDC from the VDC. |
| C.5.3.2.2 |
| Common Edits and Enhancement Module(s) (CEM) Software Edits |
| To Be Determined |
| OFFICE OF INFORMATION TECHNOLOGY (OIT)/ APPLICATIONS MANAGEMENT GROUP (AMG)/DIVISION OF SHARED SYSTEMS MANAGEMENT (DSSM) |
| Shared Systems -- Common Working File (CWF) System |
| Centers for Medicare & Medicaid Services (CMS) supplies the shared claims processing systems, including transmission to CWF, installed at the data center that the contractor must use. |
The CWF provides a single data source where MAC could verify beneficiary eligibility and receive prepayment review and approval of claims. The entire CWF database is comprised of nine single sites called Hosts. Each Host provides beneficiary entitlement and adjudication data to Medicare contractors within a specific geographic area referred to as a sector.
| C.5 ALL |
| All Contract Requirements |
| To Be Determined |
| OFFICE OF INFORMATION TECHNOLOGY (OIT)/ APPLICATIONS MANAGEMENT GROUP (AMG)/DIVISION OF SHARED SYSTEMS MANAGEMENT (DSSM) |
| Shared Systems -- Fiscal Intermediary Standard System (FISS) |
| The FISS meets the Centers for Medicare & Medicaid Services’ (CMS’) minimum core requirements and is responsible for processing Medicare Part A claims. |
CMS supplies the shared claims processing systems, including transmission to common working file (CWF), installed at the data center that the contractor must use. FISS will process claims and transactions from institutional providers. The Expert Claims Processing System (ECPS) Claims adjudication software is included within the FISS core system.
| C.5 ALL |
| All Contract Requirements |
| To Be Determined |
| OFFICE OF INFORMATION TECHNOLOGY (OIT)/ APPLICATIONS MANAGEMENT GROUP (AMG)/DIVISION OF SHARED SYSTEMS MANAGEMENT (DSSM) |
| Shared Systems – Multi Carrier System (MCS) |
| The MCS meets the Centers for Medicare & Medicaid Services’ (CMS’) minimum core requirements and is responsible for processing Medicare Part B claims. This includes, but is not limited to: data collection and validation, claims control, pricing, adjudication, correspondence, on-line inquiry, file maintenance, reports, reimbursement, and financial processing. |
CMS supplies the shared claims processing systems, including transmission to common working file (CWF), installed at the data center that the contractor must use. MCS will process claims and transactions from professional providers (physicians, practitioners, and suppliers). The Multi-Carrier System Desktop (MCSDT) is a part of the base MCS.
The System Control Facility – (SCF) Claims adjudicated software is included within the MCS core system
| C.5 ALL |
| All Contract Requirements |
| To Be Determined |
| OFFICE OF INFORMATION TECHNOLOGY (OIT)/ APPLICATIONS MANAGEMENT GROUP (AMG)/DIVISION OF SHARED SYSTEMS MANAGEMENT (DSSM) |
| Shared Systems Module -- Clinical Diagnostic Laboratory Edit Table |
| Software integrated into the shared system. Produced by the Centers for Medicare & Medicaid Services (CMS) and sent from CMS to Medicare Administrative Contractors (MACs) so that claims with laboratory services can be correctly edited and paid. |
| C.5 ALL |
| All Contract Requirements |
| To Be Determined |
| CENTER FOR CLINICAL STANDARDS AND QUALITY (CCSQ) |
| Shared Systems Module -- Code Editors |
| Software integrated into the shared system. Code Editors enforce proper use of procedural and diagnostic coding on institutional Medicare fee-for-service claims, and are programmed and produced under contract to the Centers for Medicare & Medicaid Services (CMS) by the 3M Corporation on routine annual or quarterly basis. CMS produces instructions that require the shared system maintainers to update these modules. |
| C.5 ALL |
| All Contract Requirements |
| To Be Determined |
| CENTER FOR MEDICARE (CM) / PROVIDER BILLING GROUP (PBG) /DIVISION OF INSTITUTIONAL CLAIMS PROCESSING (DICP) |
| Shared Systems Module -- Correct Coding Initiative (CCI) Edits |
| Software integrated into the shared system. These edits are designed to assure correct coding is used in billing services. Originally, Medicare implemented these edits on carrier claims. For carriers, the edits are distributed by the Centers for Medicare & Medicaid Services (CMS) through quarterly instructions. For Medicare Administrative Contractors (MACs), some of these edits are incorporated into Outpatient Code Editor (OCE) software |
| C.5 ALL |
| All Contract Requirements |
| To Be Determined |
| CENTER FOR MEDICARE (CM |
| Shared Systems Module -- Direct Data Entry (DDE) |
| Embedded in the shared system, DDE is a mode of transmitting claims using secure, dedicated hardware and communications lines. This is only a part of the Medicare Part A system – Fiscal Intermediary Standard System (FISS). |
| C.5.8 |
| Claims Processing |
| To Be Determined |
| OFFICE OF INFORMATION TECHNOLOGY (OIT)/ APPLICATIONS MANAGEMENT GROUP (AMG)/DIVISION OF SHARED SYSTEMS MANAGEMENT (DSSM) |
| Shared Systems Module -- GROUPER Software |
| Software integrated into the shared system. GROUPER software is used to bundle services that are part of specific Medicare benefits into groups for prospective payment. Not all prospective payment systems require GROUPER software. When providers submit payment groups, grouping software is found embedded at the provider site, not in Medicare systems (i.e., Home Health Agency (HHA), Skilled Nursing Facility (SNF), Inpatient Rehabilitation Facility [IRF]). However, within the Centers for Medicare & Medicaid Services (CMS), the term “GROUPER” most often refers to GROUPER software produced by 3M under contract to CMS used on inpatient hospital claims, distributed with Medicare Code Editor (MCE). |
| C.5 ALL |
| All Contract Requirements |
| To Be Determined |
| CENTER FOR MEDICARE (CM)/ PROVIDER BILLING GROUP (PBG)/DIVISION OF INSTITUTIONAL CLAIMS PROCESSING (DICP) |
| Shared Systems Module -- Health Care Common Procedure Coding System (HCPCS) File |
| Software integrated into the shared system. The Centers for Medicare & Medicaid Services (CMS) is the code set owner for these procedural codes, including codes for both items and services not included in includes Current Procedural Terminology (CPT), used on Medicare and non-Medicare claims, which are Level Two of the same greater code set that CPT codes which are copyrighted by the American Medical Association. HCPCS codes are used on professional and institutional claims, and CMS publishes fee schedules for codes in this and the CPT code set when Medicare provides fee-for-service reimbursement. HCPCS codes can be created any time during the year. These are distributed quarterly as needed via change requests, but an annual file is released to Medicare contractors every October, available electronically, and the codes are effective each January 1. HCPCS codes are also posted on the CMS website. |
| C.5 ALL |
| All Contract Requirements |
| To Be Determined |
| CENTER FOR MEDICARE (CM) |
| Shared Systems Module -- Medicare Secondary Payer (MSP) Pay Module |
| Software integrated into the shared system. MSP Pay modules calculate Medicare secondary payments. Periodic updates are issued based on policy and regulation changes. |
| C.5.14 |
| Medicare Secondary Payer |
| To Be Determined |
| OFFICE OF FINANCIAL MANAGEMENT (OFM)/FINANCIAL SERVICES GROUP (FSG)/DIVISION OF MSP PROGRAM OPERATIONS (DMSPPO) |
| Shared Systems Module -- PRICER Software |
| Software integrated into the shared systems. PRICERS are software modules programmed and produced by the Centers for Medicare & Medicaid Services (CMS) on a routine annual—unless legislation requires special quarterly implementation. These modules price benefits/services that receive bundled, prospective payment under Medicare law. PRICERS are most often updated in relation to regulatory payment policy notices or instructions. CMS directly releases PRICERS to the institutional shared system maintainers. |
| C.5.11 |
| Financial Management of Trust Fund Dollars |
| To Be Determined |
| CENTER FOR MEDICARE (CM) /PROVIDER BILLING GROUP (PBG)/DIVISION OF INSTITUTIONAL CLAIMS PROCESSING (DICP) & DIVISION OF DATA SYSTEMS (DDS) |
| Shared Systems Module -- Zip Code File |
| Software integrated into the shared system. This file is primarily intended to (1) map Zip Codes to the Centers for Medicare & Medicaid Services (CMS) carriers and localities, and also (2) maps zip codes to their States; (3) contains an urban or rural area Zip Code indicator. Distributed as frequently as quarterly through recurring instructions. |
| C.5 ALL |
| All Contract Requirements |
| To Be Determined |
| CENTER FOR MEDICARE (CM) /PROVIDER BILLING GROUP (PBG)/DIVISION OF SUPPLIER CLAIMS PROCESSING (DSCP) |
| Survey Programming Module |
| Website satisfaction survey programming module to be inserted into the Medicare Administrative Contractors’ (MACs’) provider education websites. |
| C.5.7 |
| Provider Outreach and Education (POE) |
| To Be Determined |
| CENTER FOR MEDICARE (CM)/ PROVIDER COMMUNICATIONS GROUP (PCG)/ DIVISION OF CONTRACTOR PROVIDER COMMUNICATIONS (DCPC) |
| Strategic Work Information Folder Transfer (SWIFT) |
| Official system of record for processing Freedom of Information Act (FOIA) requests |
| C.5.23.10 |
| Freedom of Information Act (FOIA) Requests |
| To Be Determined |
| OFFICE OF STRATEGIC OPERATIONS AND REGULATORY AFFAIRS (OSORA)/FREEDOM OF INFORMATION GROUP (FIG) |
| System Tracking Audit and Reimbursement (STAR) System |
| Financial management software. STAR is an automated system developed by the Centers for Medicare & Medicaid Services (CMS) for the purpose of streamlining the Medicare cost reporting process. STAR captures historical and current Medicare provider and cost report information and tracks time spent in audit and reimbursement activity on each cost report. The STAR User’s Manual serves as the instructions for implementing the program functions within the STAR system. The STAR system is also used to upload data to the Contractor Audit Settlement Report (CASR) subsystem on the CMS mainframe. |
| C.5.11 |
| Financial Management of Trust Fund Dollars; |
| To Be Determined |
| OFFICE OF FINANCIAL MANAGEMENT (OFM)/FINANCIAL SERVICES GROUP (FSG)/DIVISION OF PROVIDER AUDIT OPERATIONS (DPAO) |
| Systems documentation from maintainers |
| This is specifications that can be obtained through each system maintainer website. |
| C.5.8 |
| Claims Processing |
| At contract award and is updated each quarterly release |
| OFFICE OF INFORMATION TECHNOLOGY (OIT)/ APPLICATIONS MANAGEMENT GROUP (AMG)/DIVISION OF SHARED SYSTEMS MANAGEMENT (DSSM) |
| Toll-free telephone service |
| Toll-free network service provided through Networx, which provides access to telecommunications services using rates in the General Services Administration’s (GSA's) central telecommunications contract. |
| C.5.3 and C.4.1 |
| Infrastructure Requirements; |
Customer Service
| To Be Determined |
| CENTER FOR MEDICARE (CM)/ PROVIDER COMMUNICATIONS GROUP(PCG)/ DIVISION OF CONTRACTOR PROVIDER COMMUNICATIONS (DCPC) |
| Training materials |
| Training materials used for provider customer service staff provided on an ad-hoc basis. |
| C.5.7 |
| Provider Customer Service Program (PCSP) |
| To Be Determined |
| CENTER FOR MEDICARE (CM)/ PROVIDER COMMUNICATIONS GROUP (PCG)/DIVISION OF CONTRACTOR PROVIDER COMMUNICATIONS (DCPC) |
| Uniform Desk Review (UDR) program |
| Financial management software. The UDR is a tool used to: analyze data submitted on the provider’s cost report to identify problem areas warranting additional review and where appropriate to resolve some of those problems/exceptions; reconcile settlement data; make a determination that the cost report can be finalized without further review; or plan the field audit. |
| C.5.11 |
| Financial Management of Trust Fund Dollars |
| To Be Determined |
| OFFICE OF FINANCIAL MANAGEMENT (OFM)/FINANCIAL SERVICES GROUP (FSG)/DIVISION OF PROVIDER AUDIT OPERATIONS (DPAO) |
| Wage Index Review Program |
| The wage index measures relative differences in the average hourly wage for the hospitals in each labor market area compared to the national average hourly wage. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/wageindex.html |
| C.5.11 |
| Financial Management of Trust Fund Dollars |
| To Be Determined |
| CENTER FOR MEDICARE (CM) |
| Virtual Data Center (VDC) |
| The Centers for Medicare & Medicaid Services (CMS) VDC is comprised of both physical/technical components as well as a management structure. CMS VDC-Program Management Office (PMO) is responsible for oversight of the VDCs. The VDC PMO will serve as the customer-facing organization responsible for: |
a) Monitoring the VDCs’ relationships with all customers and assisting them in using the VDCs and other data center capabilities
b) Providing “one-stop shopping” for VDC services and the focal point for resolution of VDC-related issues
c) Oversight and program management of the deployment of new application and/or functionality to the VDCs
d) Ensuring the quality of VDC service delivery.
| C.5.3 |
| Infrastructure Requirements |
| To Be Determined |
| OFFICE OF INFORMATION TECHNOLOGY (OIT) |
| Website Satisfaction Survey Trigger Code |
| The code that a contractor shall place in its provider website code to allow for a website satisfaction survey to pop up for a sample of users. |
| C.5.7.1 |
| Provider Outreach and Education (POE) |
| To Be Determined |
| CENTER FOR MEDICARE (CM) /PROVIDER COMMUNICATIONS GROUP(PCG)/DIVISION OF CONTRACTOR PROVIDER COMMUNICATIONS (DCPC) |
January 10, 2019 Page 11 of 11
