J.7 AB MAC Award Fee Plan and Self Assessment Template.docx

Attachment J.7 A/B MAC Award Fee Plan and Self-Assessment Template

RFP# 75FCMC19R0023

FY 2019 Award Fee Plan and Self-Assessment Template

Award Fee Plan for Part A and Part B (A/B) Medicare Administrative Contractor (MAC)

(A/B MAC)

Jurisdiction E

(fill in MAC name) (fill in Contract number)

(fill in contract year, e.g., Implementation/Base, Base period, Option Year 1, Option Year 2, etc.)

Contract Period of Performance (fill in date range)

Award Fee Evaluation Period (fill in date range) Attachment J.7

Table of Contents

i ii

FY 2019 Award Fee Plan document

OVERVIEW

This document provides the Award Fee Plan for the Jurisdiction E A/B MAC contract awarded to MAC X. The performance criteria contained within this plan will be used, along with other performance related information, to determine the amount of award fee earned by the MAC.

The purpose of utilizing the award fee process is to incentivize and reward MAC excellence in the performance of contract requirements critical to program success, while the MAC meets at least minimum acceptable performance levels in all other areas.

The award fee may be awarded in whole, in part, or not at all, based on evaluated performance exceeding minimum contract requirements.

THE AWARD FEE PLAN

The award fee plan describes how the MAC will be evaluated and how the award fee will be administered. This plan identifies the criteria to be used to evaluate the MAC’s performance as it relates to the award fee criteria for the performance period. This plan also identifies the roles and responsibilities of those who will participate in the evaluations.

The Award Fee Plan:

· Is approved by the Contracting Officer (CO), the Performance Evaluation Board, and the Fee Determining Official;

· Allocates the fee pool among performance categories;

· Specifies the evaluation cycle;

· Identifies the roles and responsibilities of those who will participate in the evaluation; and

· Describes criteria for evaluating the MAC’s performance.

The FDO may unilaterally change the award fee plan prior to the beginning of an evaluation period. The MAC will be notified of changes to the plan by the CO, in writing, before the start of the affected evaluation period. Changes to this plan that are applicable to a current evaluation period will be incorporated by mutual consent of both parties.

Fee Arrangement.

The fee arrangement is negotiated based on the total estimated cost of the contract. There are regulatory limitations on total fee (cumulative base fee and award fee) for a cost plus award fee contract. The fee consists of two parts, the base fee and the award fee.

Base Fee.

The base fee (which may be zero) can be viewed as the minimum compensation for the resources a MAC uses or the investment it may undertake in order to perform the contract.

Award Fee.

The award fee is the amount of fee set aside in the contract that is available to be earned by the MAC for exceeding minimum contract requirements. The MAC is not guaranteed a minimum amount of award fee. Consequently, some, none, or the entire maximum available award fee may be earned. The amount of the fee awarded to the MAC is unilaterally determined by the government’s evaluation of MAC performance exceeding contract requirements.

Prerequisite for Eligibility for Award Fee.

In order to participate in the award fee program described in this document, the MAC must obtain at least a minimum score of “Satisfactory” in each individual perspective/evaluation criterion for the most recent Contractor Performance Assessment Reporting System (CPARS) evaluation during the evaluation period.

Performance Evaluation Periods

Measured: [Fill in award fee evaluation period, for Implementation/Base, list out separately]

With the exception of an implementation period, the award fee evaluation period begins with the first full month, and ends with the last full month of the contract period, unless otherwise specified. The final determination of the fee earned will be accomplished within 150 days after the end of the contract year.

Organizational Structure for Award Fee Administration The award fee organizational structure is established for administering the award fee provisions of this contract. The organization consists of the following:

Fee Determining Official (FDO).

The FDO is the Director, Medicare Contractor Management Group in the Center for Medicare, CMS. The responsibilities of the FDO are to:

· Approve the award fee plan and any significant changes;

· Review the Performance Evaluation Board report, MAC input, and other pertinent performance data; and,

· Make a final determination of award fee earned and payable for each evaluation period.

Performance Evaluation Board (PEB).

The PEB is comprised of the Contracting Officer’s Representative (COR); CO; CO’s Manager; Director, Division of Performance Assessment, Panel Chair; Director, MAC Program Management Division; and Director, Division of MAC Budget & Data Analysis. The responsibilities of the PEB are to:

· Review the Business Function Leads’ evaluations of the MAC’s performance;

· Consider all evaluation information from pertinent sources;

· Prepare a report to the FDO on the recommendation of an award fee to be earned by the MAC; and,

· Substantiate the recommended award fee to the FDO.

Business Function Leads (BFLs).

The BFLs are CMS staff who maintain written records of the MAC’s performance in their assigned evaluation area(s) so that a fair and accurate evaluation is obtained. The BFLs will review and consolidate periodic monitoring information for inclusion in their BFL reports, which are due to the PEB no later than 45 days after the end of the contract year.

MAC Input – to include page limitations and formatting requirements.

The MAC shall provide a written award fee performance evaluation Self-Assessment to the CO and COR within 30 calendar days of the end of the contract year. The MAC shall provide as much detail as is necessary to assist the evaluators in making its final determination; however, the written Self-Assessment shall conform to the following page limitations and formatting requirements:

· All self-assessment documents shall be submitted in Microsoft Word in Times New Roman 12 point font with 1-inch top, bottom, left and right margins.

· The Microsoft Word document shall not have any issues labeled as “errors” when the user would run the Accessibility Checker to ensure compliance with Section 508 of the Rehabilitation Act. Accessibility Checker results that are labeled as “warnings” or “tips” shall be fixed to the extent possible.

· For evaluations that have both Implementation and Operational criteria, the written Self-Assessment shall not exceed 27 pages in length (5 pages for Implementation and 22 pages for Operations).

· For evaluations that only have Operational criteria, the Self-Assessment shall not exceed 22 pages in length.

· In addition to the overall page limitation, the evaluation for the Program Improvement and Collaboration award fee criterion shall not exceed 10 pages. In addition, illustrative charts and graphs are permissible for this criteria; however, capturing all/most of the narrative in a chart with a different font is not permissible. A narrative chart must be in Times New Roman 12 point font.

· When preparing the Self-Assessment, the MAC shall use the Award Fee Self-Assessment Template provided below (the latter portion of this combined document).

· The Award Fee Plan portion of this combined Award Fee Plan and Self-Assessment document does not count towards the Self-Assessment page limit and shall not be submitted with the Self-Assessment.

Notification to the MAC.

The MAC shall receive written notification of the award fee determination within 150 days of the end of the contract year.

AWARD FEE CATEGORIES - SCORING

1. Award Fee Criteria - Summary

Award Fee Criteria for Implementation The CMS will assess MAC performance against stated criteria in the following areas:

· Successful Claims Workload Cutover

· Risk Mitigation

· Reason Code Consolidation

Award Fee Criteria for Operations The CMS will assess MAC performance against stated criteria in the following areas:

· Program Improvement and Collaboration

· Appeals - Medicare Redetermination Notice (MRN) Timeliness Part A

· Appeals - Medicare Redetermination Notice (MRN) Timeliness Part B

· Medical Review (MR) - Accuracy

· Provider Enrollment – Timeliness

· Provider Enrollment - Accuracy

· System Security – OY plans ONLY

· Quality of Desk Reviews, Audits and Reopenings – OY plans ONLY

· Comprehensive Error Rate Testing (CERT) – OY 4 ONLY

· Comprehensive Error Rate Testing (CERT) for Home Health and Hospice – OY 4 ONLY

The FDO will consider any other information available which relates to the MAC’s performance of all other contract requirements in the final determination of fee earned.

Distribution of Award Fee Pool

Implementation The award fee will be distributed in the following manner for the implementation period:

Operations The award fee will be distributed in the following manner for the operational period:

The DISTRIBUTION TABLE below varies for the Base and Option Years as two criteria are only applicable in the Option Years and the CERT criteria is only in Option Year 4 (if the MAC has a Base Year that occurred in FY14 or later).

Base Year

PM

BY

MIP

BY RAC

OY1

PM

OY 2/3/5/6

OY4 - CERT

OY4 – No CERT

*BY equals Base Year, OY equals Option Year, PM equals Program Management, and MIP equals Medicare Integrity Program

In the event that an award fee criterion is no longer applicable, CMS reserves the right to reallocate the award fee pool associated with that criterion among the remaining award fee criteria and disperse accordingly.

In addition, CMS will determine an overall adjectival rating for the MAC’s award fee performance based on the percentage of award fee earned in compliance with the chart below. If a MAC does not earn award fee because it is ineligible due to its CPARS rating(s), the overall award fee adjectival rating will automatically be “Unsatisfactory.”

REFERENCE: Federal Acquisition Regulation (FAR)16.401(e)(3)

Award Fee Process

At the end of the award fee evaluation period, the COR reviews the work performed during the period. The COR and the CMS BFLs evaluate the MAC’s performance in accordance with the performance metrics and the Statement of Work (SOW). The COR and the CMS BFLs make a recommendation regarding the percentage of fee to be awarded. This recommendation is subject to the CO’s review of the MAC’s performance of the contract.

This recommendation is provided to the PEB and, finally, the FDO. The FDO has the prerogative to change the recommendation. Within 150 days after the end of the contract year, the FDO will make a determination and an official letter will be issued by the CO advising the MAC of the award fee earned.

Award Fee Criteria – Detailed Narratives

Implementation Criteria The MAC shall be evaluated using the following implementation evaluation criteria:

Successful Claims Workload Cutover The MAC successfully implements each workload segment on the final approved implementation plan cutover date. Successful implementation means that 95 percent of clean claims are processed within the claims payment floor and ceiling specified in IOM Pub. 100-04, Chapter 1, sections 80.2.1.1 and 80.2.1.2

Risk Mitigation The MAC appropriately mitigates and/or takes action when risks affect implementation and/or operations. In addition, the MAC proactively communicates with CMS regarding any impending problems during the implementation period.

Reason Code Consolidation The MAC successfully and timely consolidates all reason codes prior to the cutover of the first workload segment (unless CMS approves a later segment cutover date).

Operations Criteria The MAC shall be evaluated using the following operational evaluation criteria:

Program Improvement and Collaboration This award fee criterion measures the MAC’s ability to: propose and implement program improvements that have a tangible or intangible benefit to the government; and collaborate with other key stakeholders to the benefit of the Medicare program. The table below provides illustrative examples of performance for each percentage category. This table is intended to serve as a guide to illustrate how CMS will determine if the MAC will earn 100 percent, 75 percent, or 50 percent of the award fee pool for this criterion.

· The MAC supports new and/or current CMS approaches to improve operational efficiency; financial stewardship of administrative and trust fund dollars; and the provider experience.

· Is the leader or has a leading role in a workgroup (such as a “lessons learned” workgroup or workgroup to address issues in an area such as Medical Review, Provider Enrollment, etc.) with other MACs which results in viable recommendations to CMS for jurisdiction-wide issues, resulting in positive program improvements and/or cost savings.

· The MAC willingly shares “workarounds” that it developed with other MACs, to the benefit of overall operations.

· The MAC takes a very active role in reviewing CMS Change Requests (CRs); offering constructive feedback when additional information or clearer direction is needed; making suggestions to CMS for how to better facilitate significant changes. The MAC provides feedback during CR testing that alerts CMS to problems with business requirements and/or potential problems with CR implementation.

· The MAC takes a very active role in reviewing National Coverage Determination (NCD) CRs. The MAC offers constructive feedback when additional information or clearer direction is needed during the business requirement (BR) development phase prior to the point-of-contact (POC) review, and makes suggestions to CMS to better facilitate significant claims processing changes. The MAC provides feedback during CR testing that alerts CMS to problems with BRs and/or potential problems with CR implementation.

· When developing proposed local coverage determinations (LCDs), the MAC makes an effort to consult with external stakeholders and healthcare professionals to discuss evidence and guidelines, without discussion of the potential decision.

· The MAC takes the lead in researching and authoring LCDs, ensures quality evidentiary review and explanation of the evidence, shares related evidentiary information with other MACs, has at least one LCD developed with, or adopted by one or more MACs outside of its corporate entity. The MAC promotes LCD transparency with external stakeholders (i.e., explains the LCD process, the analysis of the evidence and how the MAC made its decision based on the evidence) or provides data/evidence to other MACs to support the rewrite or retirement of an LCD.

· The MAC consistently and willingly takes the lead or leading role in workgroups that provide recommendations to CMS to improve operational efficiencies by addressing claims processing/code editing issues that arise post NCD implementation.

· Participates in a workgroup (such as a “lessons learned” workgroup or workgroup to address issues in an area such as Medical Review, Provider Enrollment, etc.) with other MACs that results in viable recommendations to CMS for jurisdiction-wide issues.

· The MAC consistently and willingly participates in LCD workgroups and conferences.

· The MAC takes an active role in reviewing CMS CRs; offering constructive feedback when additional information or clearer direction is needed; making suggestions to CMS for how to better facilitate significant changes.

· The MAC takes an active role in reviewing CMS CRs during the NCD implementation development process prior to POC reviewing; offers constructive feedback when additional information or clearer direction is needed; makes suggestions to CMS to better facilitate significant claims processing changes.

· For some of the proposed LCDs developed, the MAC makes an effort to consult with external stakeholders and healthcare professionals to discuss evidence and guidelines, without discussion of the potential decision.

· The MAC has implemented at least one LCD that was authored by another MAC (outside the MAC’s corporate entity) and/or the LCD workgroup or considers the revisions or retirement of a policy from another MAC and/or the LCD workgroup (i.e., based on the evidence provided by another MAC).

· The MAC takes an active role on workgroups that provide recommendations to CMS to improve operational efficiencies by addressing NCD claims processing/code editing issues.

· The MAC participates in policy coordination and collaboration activities.

50%

· The MAC proposes process improvements or innovations that may provide tangible or intangible benefit to the government.

· Participates in a workgroup (such as a “lessons learned” workgroup or workgroup to address issues in an area such as Medical Review, Provider Enrollment, etc.) with other MACs.

· The MAC occasionally takes an active role in reviewing CMS CRs; offering constructive feedback when additional information or clearer direction is needed; making suggestions to CMS for how to better facilitate significant changes.

· The MAC occasionally takes an active role in reviewing CMS CRs prior to the POC review process; offers constructive feedback when additional information or clearer direction is needed; makes suggestions to CMS for how to better facilitate significant claims processing changes.

· MAC participates in LCD and NCD collaboration and implementation workgroups.

The data source for this criterion is the CO and the COR who will evaluate on an ongoing basis.

Appeals - Medicare Redetermination Notice (MRN) Timeliness – Part A This criterion measures the Medicare Administrative Contractor’s (MAC’s) timeliness in processing and sending 100 percent of Part A redetermination notices within 60 calendar days of receipt during the award fee evaluation period.

Eligibility:

In order to be eligible for participation in this criterion, the MAC shall process at least 90 percent of redetermination cases within 60 calendar days of receipt for each month of the award fee evaluation period. If the MAC has one or more months during the period in which the MAC does not successfully process and send 90 percent or more redeterminations within 60 calendar days, the MAC is not eligible for participation in this criterion.

Award Fee:

The award fee for this criterion will be earned based on the number of months the MAC achieves a 100 percent performance level during the award fee evaluation period. Part A will be calculated, evaluated, and awarded separately from Part B for each award fee evaluation period. The percentage of award fee earned will be calculated by dividing the number of months that the 100 percent timeliness standard was met by the total number of months in the award fee evaluation period. For example, if there are six (6) months in the award fee evaluation period and the MAC achieves the 100 percent rate for four (4) of the six (6) months, the MAC would earn 67 percent of the award fee for this criterion. The amount of award fee earned is rounded to the nearest whole percentage. In the example above, 4 of 6 months yields 66.66 percent, rounded to 67 percent award fee.

Data:

The data required to conduct this review is pulled from the Medicare Appeals System (MAS), unless the MAC continues to process legacy redeterminations. Legacy redeterminations data are reported on the Centers for Medicare & Medicaid Services (CMS) Contractor Reporting of Operational and Workload Data (CROWD) CMS-2592 Monthly Statistical Report on Intermediary and Carrier Part A and Part B Appeals Activity Form.

Redetermination Workloads in MAS Part A MACs have transitioned from processing redeterminations, and reporting such redetermination workloads on Lines 15 and 16 of the CMS 2592 report; redetermination workloads are processed solely in MAS. The data used for the award fee evaluation is reported on the Appeals Decided Monthly Breakdown – Timeliness Report in MAS. The only exception is when redetermination legacy cases are part of the workload, as described below.

Reporting CMS 2592 Legacy Redetermination Cases For any legacy redetermination cases, CMS will also review data from Lines 15 and 16 on the CMS 2592 report. As applicable, data from the MAS will be combined with data from the CMS 2592 report for any MAC that still reports legacy redeterminations data on Lines 15 and 16 on the CMS 2592 report. Note that data for redetermination legacy cases will continue to be tracked on the CMS 2592 report. Redetermination timeliness from the CMS 2592 report is calculated by dividing the sum of redeterminations cleared in 60 days (Line 15) by the total cleared (Lines 15 + 16). Redeterminations for which additional documentation is submitted are not included in this calculation.

The review of monthly numbers throughout the year is done for internal monitoring purposes. For award fee evaluation purposes, the data provided in the self-assessment, along with the CMS reports run at the end of the evaluation period, serve as the data source for this award fee criterion.

Completing the Self-Assessment Template MACs that process redeterminations workloads solely in MAS and did not report any redetermination timeliness cases on the CMS 2592 report are not required to enter “ZEROs” in the 2592 monthly columns. Check “NO” when responding to the self-assessment question pertaining reporting cases on the CMS 2592 report. However, if one or more redetermination timeliness legacy cases is tracked on the CMS 2592 report during the evaluation timeframe, data must be reported in the appropriate 2592 columns in the table.

Calculating Award Fee at the Conclusion of the Option Year

CMS:

On the 15th day of the month, following the conclusion of a MAC’s option year, CMS will run the Appeals Decided Monthly Breakdown – Timeliness Report for all MACs, to include data for each month within the range of months included in the option year. The running of the report will occur after the daily update cycle in MAS is completed. As appropriate, data from this report will be combined with monthly totals from the CMS 2592 report for any MAC that also reports data on Lines 15 and 16. The combination of these two reports will be used by CMS to determine whether the award fee is met. Before conducting the award fee evaluation, CMS staff will verify the data used for review.

MAC:

In addition to the self-assessment template that is due to CMS 30 days after the end of the period of performance being evaluated, the MAC shall provide the Appeals Decided Monthly Breakdown – Timeliness Report as an attachment. This report shall be run on the 15th of the month following the close of the option year, and shall include totals for each month of the option year range. The running of the report will occur after the daily update cycle in MAS is completed.

In addition to providing the MAS report noted above, and as applicable, MACs that still report legacy workloads on the CMS 2592 report shall also be prepared to provide screen prints showing data from the applicable lines and columns of the CMS 2592 report, upon request. This information will only be requested if a discrepancy that cannot easily be verified or explained exists between the CMS 2592 data and the award fee evaluation self-assessment data provided by the MAC. These separate attachments will not be counted as part of the self-assessment page count.

The evaluation of this criterion will be completed as a desk review, by CMS.

Rounding:

The performance threshold for this evaluation is set at 99.95 percent. Performance percentages are displayed with two decimal places. Normal rounding procedures are employed to determine all percentages. For example, completing 21,001 of 21,012 cases timely will provide a result of 0.999476. This result is rounded and displayed with two decimal places for a final result of 99.95 percent. Likewise, completing 21,000 of 21,012 cases timely will provide a result of 0.999429. This result is rounded and displayed with two decimal places for a final result of 99.94 percent.

In determining whether award fee performance expectations are met, use the following example as a guide: since the performance threshold is established at 99.95 percent, a percentage of 99.95 or higher will satisfy CMS requirements. A performance percentage of less than 99.95 will fall below the performance threshold and CMS requirements would not be met in this instance.

Appeals - Medicare Redetermination Notice (MRN) Timeliness – Part B This criterion measures the Medicare Administrative Contractor’s (MAC’s) timeliness in processing and sending 100 percent of Part B redetermination notices within 60 calendar days of receipt during the award fee evaluation period.

Eligibility:

In order to be eligible for participation in this criterion, the MAC shall process at least 90 percent of redetermination cases within 60 calendar days of receipt for each month of the award fee evaluation period. If the MAC has one or more months during the period in which the MAC does not successfully process and send 90 percent or more redeterminations within 60 calendar days, the MAC is not eligible for participation in this criterion.

Award Fee:

The award fee for this criterion will be earned based on the number of months the MAC achieves a 100 percent performance level during the award fee evaluation period. Part B will be calculated, evaluated, and awarded separately from Part A for each award fee evaluation period. The percentage of award fee earned will be calculated by dividing the number of months that the 100 percent timeliness standard was met by the total number of months in the award fee evaluation period. For example, if there are six (6) months in the award fee evaluation period and the MAC achieves the 100 percent rate for four (4) of the six (6) months, the MAC would earn 67 percent of the award fee for this criterion. The amount of award fee earned is rounded to the nearest whole percentage. In the example above, 4 of 6 months yields 66.66 percent, rounded to 67 percent award fee.

Data:

The data source for this criterion is the Centers for Medicare & Medicaid Services (CMS) Contractor Reporting of Operational and Workload Data (CROWD) CMS-2592 Monthly Statistical Report on Intermediary and Carrier Part A and Part B Appeals Activity Form. Redetermination timeliness is calculated by dividing the sum of redeterminations cleared in 60 days (Line 15) by the total cleared (Lines 15 + 16). Redeterminations for which additional documentation is submitted are not included in this criterion.

The evaluation of this criterion will be completed as a desk review, by CMS.

Rounding:

The performance threshold for this evaluation is set at 99.95 percent. Performance percentages are displayed with two decimal places. Normal rounding procedures are employed to determine all percentages. For example, completing 21,001 of 21,012 cases timely will provide a result of 0.999476. This result is rounded and displayed with two decimal places for a final result of 99.95 percent. Likewise, completing 21,000 of 21,012 cases timely will provide a result of 0.999429. This result is rounded and displayed with two decimal places for a final result of 99.94 percent.

In determining whether award fee performance expectations are met, use the following example as a guide: since the performance threshold is established at 99.95 percent, a percentage of 99.95 or higher will satisfy CMS requirements. A performance percentage of less than 99.95 will fall below the performance threshold and CMS requirements would not be met in this instance.

Medical Review - Accuracy This criterion measures the accuracy of the MAC’s medical record review decisions (please refer to Chapter 3 of the Program Integrity Manual for a definition of medical record review). To achieve this objective, CMS will select a random sample of Part A and Part B claims (herein, “claims” shall refer to claim lines, unless not applicable, such as with Diagnosis Related Group (DRG) claims) that the MAC has conducted medical record review on either a prepayment or post-payment basis, or a combination of both, during the evaluation period. This sample shall exclude those claims that were reviewed on either a prepayment or post-payment basis by the Recovery Auditors, Zone Program Integrity Contractors (ZPICs)/Unified Program Integrity Contractors (UPICs), Supplemental Medical Review Contractor (SMRC), Comprehensive Error Rate Testing (CERT), or other review entity; subjected to prior authorization; or selected by CMS for probe and educate concurrent review or monthly accuracy review process (to the degree known at the time the universe file is compiled).

Step-by-Step Process

Step 1: Providing the Universe File

Each month, the MAC shall supply the Accuracy Review Contractor (ARC) with one file containing a list of the entire universe of claims that were subjected to medical record review. This universe shall contain finalized claims from two months prior. This list must comply with the specified format provided by the ARC and be received by the ARC by the first business day of the month.

This universe file list shall be submitted via one of the following methods:

· Encrypted/secure compact disc (CD) to:

Renu Sharma/Sarah Ramos Accuracy Review Contractor 1530 E Parham Road Henrico, VA, 23228

On or before the required submission date, the password shall be emailed to Renu Sharma (sharmar@admedcorp.com) and Sarah Ramos (ramoss@admedcorp.com) with a copy to Sarah Leipnik (Sarah.Leipnik@cms.hhs.gov).

· Email attachment to:

sharmar@admedcorp.com and ramoss@admedcorp.com

On or before the required submission date, the password shall be communicated to Renu Sharma or Sarah Ramos adhering to CMS encryption of sensitive information security policies (Fax: 804-264-9764; Telephone: 804-864-9957 or 804-864-9978).

· Secure Electronic File Transfer to the secure file website (https://securefiles.admedcorp.com/)

Step 2: Sample Selection

The sample will be pulled from the universe of claims on which medical record review was conducted throughout the period of performance. Using random sampling, approximately 10 claims will be selected each month of the evaluation period to achieve the required total claim count within the award fee period. The ARC will notify the MAC of the sample claims selected for review within three business days after the first business day of the month. If the award fee evaluation period is seven months or less in length, a total of 50 claims will be selected for review during the award fee period. If the award fee evaluation period is eight months or greater in length, a total of 100 claims will be selected for review during the award fee period. There will be no claims selected from the last two months of the award fee evaluation period to allow for timely evaluation and dissemination of results by CMS.

Step 3: Submission of Documentation to the ARC

The MACs shall submit the complete documentation package for the sampled claims to the ARC so that it is received within five business days of the date of the notification letter. This documentation package shall include:

1. All documents reviewed by the MAC, for all lines on the claim subjected to medical record review, when making the medical record review decision;

2. The barcoded coversheet for each claim;

3. Documentation indicating the specific focus of the review; and

4. Documentation of the determination made (paid, denied, reduced) and the detailed rationale behind the determination (nurses notes, screen shots of internal resources or the Common Working File, denial codes with explanations and/or denial letters, information about technical or system denials and reductions that occurred after the medical record review).

It is important the MACs submit all documentation to support the medical record review decision to the ARC because, in general, the CMS dispute panel will not consider additional documentation sent to CMS as part of a dispute request that was not in the documentation package submitted to the ARC.

The documentation package shall be submitted via one of the following methods:

· Postal mail to:

Renu Sharma/Sarah Ramos Accuracy Review Contractor 1530 E Parham Road Henrico, VA, 23228

· Fax to:

Accuracy Review Contractor 804-264-9764

· Encrypted/secure CD to:

Renu Sharma/Sarah Ramos Accuracy Review Contractor 1530 E Parham Road Henrico, VA, 23228

On or before the required submission date, the password shall be emailed to Renu Sharma (sharmar@admedcorp.com) and Sarah Ramos (ramoss@admedcorp.com) with a copy to Sarah Leipnik (Sarah.Leipnik@cms.hhs.gov).

· Email Attachment to:

sharmar@admedcorp.com and ramoss@admedcorp.com

1. The MAC shall only submit the complete documentation package for the sampled claims to the ARC via encrypted/secure email when the file size is 15 megabytes (MB) per attachment, for a maximum file size of 30 MB per email. If the documentation package file size is larger than 30 MB, the MAC shall not send multiple email submissions to the ARC, but shall use an alternative documentation submission method.

2. On or before the required submission date, the password shall be communicated to Renu Sharma or Sarah Ramos adhering to CMS encryption of sensitive information security policies (Fax: 804-264-9764; Telephone: 804-864-9957 or 804-864-9978).

3. Images must be in either TIF or PDF format.

· Secure Electronic File Transfer to the secure file website (https://securefiles.admedcorp.com/)

Step 4: Review of Claims

Independent ARC reviewers will re-review these sampled claims, utilizing the same documentation that the MAC used in the original review, to evaluate the accuracy of the MAC’s medical record review determination. In other words, the independent reviewers will re-review these claims to ensure they were properly paid or denied based on Medicare coverage, coding, and billing rules. The review will be pass/fail (i.e., no partial credit will be applied, such as when a Part A inpatient hospital claim is deemed inappropriately paid and could have been rebilled under Medicare Part B). These reviews will be completed within 13 business days. Open communications between the MAC and the ARC will not be allowed during the period of claims review. This is to ensure the fairness and objectiveness of the reviews. However, on a case-by-case basis, CMS may allow for communication between the MAC and ARC for the purpose of clarifying issues that may result in a preventable error finding (e.g., an explanation of submitted error codes, focus of review, and information about technical or system denials and reductions that occurred after the medical record review). This communication must be facilitated and approved by CMS.

These results will be posted to the ARC Claim Status Website (CSW) one day after completion of the ARC reviews for the month. The ARC will notify the MAC when the review results information is available.

Step 5: Review of Agree Claims

As part of the CMS quality control oversight of the MR Accuracy Award Fee project, each month CMS reviews a random sample of claims where the medical record review decision of the ARC and the MACs are the same (that is, agree claim). These claims are already included in the MAC’s MR Accuracy Award Fee sample. The agree claims are selected from the same month as the sample claims. The MAC will be notified of an agree claim selection only when the CMS review decision of the agree claim is not the same as the ARC and MAC.

When the CMS review decision of an agree claim is not the same as the ARC and MAC, the claim is counted as an inaccurate determination (i.e., fail) and will follow the process below:

· CMS will notify the MAC of the CMS decision, including the CMS review comments, via email on the same day that CMS finalizes the results for that month’s disputes.

· The MAC will have seven business days to request a dispute review with CMS for the failed agree claim. The MAC shall submit an email dispute request to its CMS COR, with a copy to Sarah.Leipnik@cms.hhs.gov and Heather.Wetherson@cms.hhs.gov, which includes the rationale for the dispute. CMS will issue a final determination to the agree claim dispute via email as soon as it is available.

· Once finalized, CMS will update, as needed, the CMS agree claim determination on the ARC CSW.

The final CMS determination on the claim will be included in the MAC’s Award Fee evaluation at the end of their Award Fee period.

Step 6: Disputes

Should the independent reviewer come to a different decision than the MAC, the MAC will have the option of disputing this finding with CMS. Each MAC has seven business days from the day the results are posted to the ARC CSW to request a dispute review with CMS. Each MAC shall request the dispute via the ARC CSW. Additionally, the MAC shall submit an email request for a CMS dispute review to its CMS COR, with a copy to Sarah.Leipnik@cms.hhs.gov and Heather.Wetherson@cms.hhs.gov, which includes the rationale for the dispute. In general, the CMS dispute panel will not consider additional documentation sent to CMS as part of a dispute request that was not in the documentation package submitted to the ARC. However, on a case-by-case basis, the MAC may request consideration to submit additional documentation to CMS. CMS expects this would be permitted in rare situations for the purpose of clarifying issues that may result in a preventable error finding (e.g., illegible documentation).

Using the medical record and systems information available to the ARC, the CMS dispute panel will complete the review. If supporting evidence for the dispute is missing or lacking, the CMS dispute panel will uphold the adverse decision. CMS will enter the results information into the ARC CSW and the MAC will be notified via email when this information is available. If the CMS dispute panel identifies a new issue that is within the specific focus of the MAC review, not identified by the ARC, and would result in an adverse decision for the MAC, the MAC will have the option of disputing this new finding with CMS.

The MAC has three business days from the day the dispute results are posted to the ARC CSW to request a new finding dispute review with CMS. The MAC shall submit an email request for a CMS dispute review to its CMS COR, with a copy to Sarah.Leipnik@cms.hhs.gov and Heather.Wetherson@cms.hhs.gov, which includes the rationale for the dispute. In general, the CMS dispute panel will not consider additional documentation sent to CMS as part of a new finding dispute request that was not in the documentation package submitted to the ARC. However, on a case-by-case basis, the MAC may request consideration to submit additional documentation to CMS. CMS expects this would be permitted in rare situations for the purpose of clarifying issues that may result in a preventable error finding (e.g., illegible documentation).

Using the medical record and systems information available from the original CMS dispute panel and the newly submitted MAC dispute rationale, the CMS dispute panel will complete the new finding review. If supporting evidence for the dispute is missing or lacking, the CMS dispute panel will uphold the adverse decision. CMS will enter the results information into the ARC CSW and the MAC will be notified via email when this information is available.

Step 7: Calculating the Accuracy Rate

The formula for calculating the accuracy rate is 100 multiplied by the number of claims where the MR staff made an accurate determination divided by the number of claims in the sample.

The formula is displayed mathematically as shown below:

100 X (# of claims where MR staff made an accurate determination) = Accuracy Rate # of claims in the Sample

Award fee for this criterion will be earned as follows:

Trial Month for New Contracts

For any MAC contract starting its first MR accuracy evaluation periods during FY 2019, the first scheduled month of the MR Accuracy award fee criterion award fee period will be used as a trial month. During this trial period, all steps will be followed by both the MAC and the ARC, including medical review, but the results will not count toward the award fee criterion. The process outlined above shall be followed by the MACs during the trial month. For example, MACs with MR Accuracy award fee periods beginning in January 2019 shall submit its universe of claims for that month to the ARC on the first business day of March 2019. The month of January will be considered the trial month.

During review of the trial month’s claims, the ARC will identify any technical, medical documentation, or other issues that may impact the ability to conduct fair and thorough reviews in accordance with the MR Accuracy award fee criterion. CMS will discuss with the ARC and the MAC any issues identified during the trial month, as needed, after the trial month has been completed. This process will be used as a means to mitigate future problems that may lead to preventable error findings.

Adjudication of Claims…