J.23 Government Provided Proposal Assumptions (GPPA).docx

Attachment J.23 Government Provided Proposal Assumptions (GPPA)

RFP # 75FCMC19R0041

GOVERNMENT PROVIDED PROPOSAL ASSUMPTIONS

See Section L.13

1. CONTRACT AWARD DATE

The Centers for Medicare & Medicaid Services (CMS) anticipates awarding the Durable Medical Equipment (DME) Medicare Administrative Contractor (MAC) contract for Jurisdiction C (JC) on or about September 28, 2020, with a contract effective date of October 1, 2020. JC includes the states of Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, U.S. Virgin Islands, Virginia and West Virginia.

2. IMPLEMENTATION CUTOVER DATE

a. Implementation Cutover Date The Offeror shall use the Implementation cutover dates developed by CMS (see table below) when developing its proposed Contract Line Item Number (CLIN) 0001 costs associated with its Jurisdiction Implementation Project Plan. Completion of the movement of the Jurisdiction to the incoming MAC shall occur as specified in Table 2 below. The Offeror shall assume that CMS will assign new Medicare workload identification numbers to the JC DME workload, effective at cutover, consistent with Change Request (CR) #6259.

At the implementation cutover date, the outgoing MAC ceases Medicare operations and the incoming MAC begins to perform Medicare business functions (CLIN 0002) for that jurisdiction. The following table considers each individual Customer Information Control System (CICS) Production region as an individual “segment.” Table 1 below identifies all of the CICS Production regions in JC. In addition, the breakdown of User Acceptance Testing (UAT) regions for JC mirrors the configuration (the same number and breakdown) of Production regions for JC.

For proposal purposes, the Offeror shall assume that CMS will support the build-out of new CICS production and UAT regions to mirror the configuration employed by the outgoing MAC as shown in Table 1, in order to support simulation testing and the conversion of claims history to the Offeror’s own claims history edit/audit taxonomy; further, the Offeror shall assume that CMS will arrange for necessary implementation support from the maintainers of the ViPS (Viable Information Processing Systems) Medicare System (VMS) and Common Working File (CWF) systems as well as the Virtual Data Center and the CWF host; provided, however, the Offeror may propose an alternative approach to Implementation period simulation testing, claims history, and CICS region build-out as permitted by (and only as permitted by) the proposal submission instructions at RFP, L.14.5, Tab F.

Table 1: Implementation Cutover Dates

b. Health Insurance General Ledger and Accounting System (HIGLAS)

DME contracts are currently working towards transitioning to HIGLAS. The HIGLAS transitions for all four DME contracts are scheduled for early Calendar Year 2020. For proposal purposes, Offerors should assume all workloads have been converted to HIGLAS; moreover, Offerors shall assume that the JC accounting operations have already been consolidated to one HIGLAS "organization ID" for DME.

c. Joint Operating Agreements (JOAs); Operational Start Dates; CLIN Start/End Dates

Joint Operating Agreements between functional contractors impacting the new MACs shall be executed prior to the operational start date. (See the Statement of Work section F.1.1 for more information on required JOAs.) The operational start date is defined as the date that the MAC assumes all Medicare functions from an outgoing contract and is capable of processing Medicare claims for that jurisdiction. Please refer to the implementation cutover dates in the chart above for the operational start date. The dates are depicted in the timeline below:

Implementation and Base Periods: 10/01/2020 – 09/30/2021

Contract Effective Date Implementation Start

Implementation and Base Periods are shown below:

CLIN 0001 – Implementation

End of CLIN 0001

CLIN 0002 – Base Period

Table 2: Estimated Period of Performance Dates for CLINs 0001 – 0016

3. PM & MIP PROVIDER/SUPPLIER CUSTOMER SERVICE, PROVIDER/SUPPLIER OUTREACH AND EDUCATION (SOW D.5.1 and E.4.6) For PM & MIP Provider/Supplier Customer Service, Provider/Supplier Outreach and Education activities, the Offeror shall reference the table below which represents the provider/supplier population for the specified Jurisdiction by state. It is up to the Offeror to determine the workload appropriate for each type of provider/supplier outreach and education activity. There are no minimum staffing requirements for this function, as long as SOW (Attachment J.1) and IOM requirements are met. Offerors must develop their own strategy for how they can best service the provider/supplier population. Any assumptions or narrative explanations shall be included in Proposal Volume II, Tab C, Offeror Proposal Assumptions.

NOTE: The DME MAC has jurisdiction for durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) claims based on a “beneficiary residence” rule, so the DME MAC will also interact with some DMEPOS suppliers from outside these states.

Table 3: PM and MIP Supplier Counts

4. ELECTRONIC DATA INTERFACE INQUIRIES

For proposal purposes, the Electronic Data Interface Inquiries (EDI) workloads are included in the overall inquiries workloads provided in the BOE (Attachment J.22). Offerors shall prepare proposals assuming that a workload transition will generate higher EDI inquiries during the Implementation and Base Year of the contract.

5. CHANGE REQUESTS

CMS updated SOW section C.4 Change Management Process Requirements to remove the specific 25,000 hours reference. The change management information provided in the Basis of Estimate (BOE) remains the same. Offerors shall use the BOE as directed for proposal purposes. CMS issues approximately 633 draft change requests (CRs) to Medicare Contractors, Shared System Maintainers (SSMs), and the Common Working File (CWF) Maintenance Contractor for review and comment each year. This is otherwise known as the Point of Contact (POC) Review period, which is described in detail in section C.4.1 of the SOW, Participation in Change Management Process and includes the review of corrections. On average, a draft CR will go through approximately three rounds of POC review. Annually, approximately 155 of the draft CRs are issued in final for implementation and approximately 50 corrected CRs are issued annually. Annually, approximately 100 of those issued CRs result in changes to the DMEPOS claims processing systems, VMS and CWF. See the BOE (Attachment J.22) for specific workload assumptions.

6. REFERENCES TO MANUALS IN THE SOW

The Offeror shall prepare their proposal based upon the version of the Manuals (both the Internet-Only Manual (IOM) and Paper-Based Manuals) as of the date of the RFP release. In the event of any conflict, the Statement of Work (Attachment J.1) has precedence over the IOM, which in turn has precedence over the Paper-Based Manuals. The Offeror shall not respond to manual changes issued after the RFP release date unless otherwise instructed by CMS.

7. RECORDS RETENTION ASSUMPTIONS

For DME MAC Jurisdiction C the Offeror shall assume 55,065 boxes of hard copy Medicare records located in an Iron Mountain facility. The current breakout of this total by locale is provided in the chart below. All boxes are currently stored in a National Archives and Records Administration (NARA) compliant facility that is certified by CMS and approved by NARA. These boxes are not required to be moved, but they must be maintained as directed by CMS in a NARA certified facility.

For proposal purposes, the Offeror may assume that zero (0) boxes of Medicare records will need to be moved to a CMS certified NARA compliant facility. The approximately 55,065 boxes of hard copy Medicare records for this Jurisdiction may be transferred via a tri-partite agreement (or a chain of custody agreement) between the current JC contractor, their file storage subcontractor, and the incoming JC contractor. CMS will approve this subcontract agreement prior to final execution by all parties. If the Offeror is moving these files, they need to be moved prior to the end of CLIN 0002 Base Year of the new JC contract.

The Offeror shall also include in their proposal (CLINs 0002 – 0008) the ongoing costs of storing a total of 55,065 boxes of Medicare records in a NARA compliant facility. The Offeror shall also provide an estimate of additional and ongoing storage costs for boxes of any hard-copy program records to be created during the performance of this new JC contract, and include these costs in their proposal. For instance, records created during CLIN 0002 would need to be stored for the balance of CLIN 0002, as well as for CLINs 0003-0008 (to the extent required by the federal records destruction schedule), etc. For proposal purposes, Offerors shall use the conversion factor that one (1) box = 1.2 cubic feet.

Table 4: Records Storage Facilities

8. MANAGEMENT PAPER BILLS/CLAIMS

In the management of paper bills and claims addressed in the Statement of Work, section D.1.1.2.1 (Attachment J.1), the electronic images from the outgoing contractor will be transferred to the incoming contractor. For proposal purposes, the Offeror shall assume that the formats of these images are compatible with their systems. Additional information regarding the images from the outgoing contractor will be provided after contract award and during the implementation period.

9. ELECTRONIC DOCUMENT AND DATA RETRIEVAL

For obtaining, reading and storing historical electronic files addressed in the Statement of Work, section C.2.2.3 (Attachment J.1), for proposal purposes, Offerors shall assume that historical electronic file formats are compatible with their systems. Additional information will be provided after contract award and during the implementation period.

10. DME COORDINATION MEETINGS

Section E.4.8 of the Statement of Work (Attachment J.1), addresses DME Coordination Meetings (DCMs). For proposal purposes, Offerors need to include the cost of scheduling, coordinating, and facilitating two DCM meetings per year.

11. PARTICIPATION IN CONFERENCES

In accordance with Section C.3.5.1 of the Statement of Work (Attachment J.01), the contractor shall participate in conferences. For proposal purposes, Offerors should plan for 12 conferences annually, four (4) attendees at each conference, and two (2) overnights at each conference.

In addition to the 12 conferences, the Offeror shall also propose to attend two (2) CMS Security Control Oversight and Update Training (CSCOUT) conferences annually in February and August, with three (3) overnights at each conference attended by the MAC System Security Officer (SSO).

Additionally, the Offeror should propose to the following conferences and workgroups in the Provider Customer Service (PCSP) functional area: (a) Provider Customer Service Program Conference once a year (up to five (5) contractor staff may attend). Attendees will typically include a high-level representative from provider outreach and education, provider contact center, and provider self-service (Interactive Voice Response (IVR) system, website, portal). (b) Monthly Provider Customer Service Program User Group teleconference. Contractor jurisdiction representatives knowledgeable about provider outreach and education activities, provider contact center operations (telephone and written inquiries), and IVR, website, and portal operations/functions may attend. (c) Periodic workgroups (about two (2) per year) with CMS staff to address PCSP issues. Generally, a contractor jurisdiction would have two (2) representatives on each workgroup (a primary and a secondary) who are familiar with the issues to be addressed. The workgroups always meet by teleconference, usually on a monthly basis.

In addition to the proposal assumptions provided above for section C.3.5.1, Offerors shall propose any travel required to perform other requirements in the statement of work. Additional travel may include, but is not limited to, the following sections of the SOW:

12. PROVIDER/SUPPLIER OUTREACH AND EDUCATION – DIRECT MAILINGS

For proposal purposes, Offerors shall plan for two (2) direct mailings a year, to all enrolled providers/suppliers within their jurisdiction, in accordance with the Internet Only Manual Pub 100-9, Chapter 6 located at: IOM Pub 100-9, Chapter 6 (https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/com109c06.pdf)

13. BANKING

CMS provides banking services to MACs through standard commercial banking contracts between the commercial bank and CMS. The new DME JC MAC workload will be assigned to US Bank for their MAC Medicare Bank Account.

Effective February 2012, CMS no longer provides lockbox services as part of these standard commercial banking contracts. Therefore, Offerors shall include as part of this proposal any costs associated with creating their own subcontract for lockbox services. If the Offeror utilizes lockboxes, but wishes to change their banking procedures for this contract such that lockboxes are no longer needed for MAC functions, the Offeror shall include all associated implementation costs in their proposal.

Scenario: The MAC Contractor could coordinate with CMS and its assigned bank to open a lockbox and link that lockbox with the MAC’s Medicare Bank Account. In this example, the MAC Contractor would have to form a separate subcontract with the Bank to pay for the use of the lockbox, which shall be billed as an expense to the MAC Contract for which it has been established.

14. FREEDOM OF INFORMATION (FOIA) REQUESTS

Offerors will note that Freedom of Information Act (FOIA) workload has been included in the BOE (Attachment J.22).

15. STATEMENT OF STANDARDS FOR ATTESTATION ENGAGEMENTS #18

CMS updated SOW section C.3.3 Statement on Standards for Attestation Engagements 18 (SSAE 18), Offerors will no longer be required to procure a contract with an audit firm for the SSAE 18 audits. All MACs will be required to comply with the Statement of Standards for Attestation Engagements #18 (SSAE 18) auditing procedures as described in the SOW (Attachment J.1) section C.3.3.

16. MEDICARE BENEFICIARY IDENTIFIER (formerly known as SOCIAL SECURITY NUMBER REMOVAL INITIATIVE) The passage of the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 (PL 114-10 s.501) on April 16, 2015, legislates the replacement of the Social Security Number (SSN) based Health Insurance Claim Number (HICN) from the Medicare Card. Implementation of this law occurred in April 2019. For proposal purposes, Offerors will be aware that instructions and future direction on the New Medicare Card will be directed through the Change Request Process as necessary.

17. WEB PORTAL INQUIRIES TRANSACTIONS

CMS has removed the Web Portal Inquiries workload subcategory from the Provider Inquiries workload category in the BOE. Additional rows have been added to the BOE to provide the number of Web Portal Inquiries - Transactions Received and Web Portal Inquiries - Transactions Returned, as defined in the Instructions tab of the Basis of Estimate. Offerors have been provided the workload numbers for Web Portal Inquiries - Transactions Received and Web Portal Inquiries - Transactions Returned for proposal purposes. Offerors shall apply their own local experience to determine and propose to the portion of web portal inquiries transactions that require some level manual intervention.

18. PROVIDER/SUPPLIER TELEPHONE INQUIRIES

For proposal purposes, CMS provided Attachment J.23.B, Government Provided Proposal Assumptions CSR-Handled Telephone Inquiries Tables, which shall be completed by all Offerors. Offerors shall provide additional data and details in proposals as directed in Volume II, Tab C, Offeror Proposal Assumptions and Volume III, Tab F, RFP L.14.5. Specifically, for the provider/supplier telephone inquiry workload, the Offeror shall provide the basis for the Offeror's proposed CSR-handled telephone inquiries workload volume; if the Offeror proposes to adjust (overwrite) the CMS-provided CSR-handled telephone inquiry workloads in Column F, the Offeror's explanation for doing so must be clear and complete.

19. OUTGOING CONTRACTOR PENDING AND BACKLOGS

For proposal purposes, Offerors will anticipate all pending workloads will be within acceptable, normal ranges. In addition, Offerors will assume any known backlogs are included in workloads provided in the BOE (Attachment J.22).

20. HOMELAND SECURITY PRESIDENTIAL DIRECTIVE (HSPD) 12

Offerors will be aware that instructions and future direction on HSPD 12 (policies for a common identification standard for federal employees and contractors) and Personal Identity Verification (PIV) credential requirements will be directed through the Change Request Process as timeframes and related activities are determined. For proposal purposes, Offerors are required to include estimated costs to comply with solicitation section H.20 CMS Security Clause (APR 2016) only.

21. MEDICAL REVIEW WORKLOADS

Offerors will be aware that the several Medical Review workload subcategories and numbers provided in the BOE (Attachment J.22) have been developed based on CR 9809 and CR 10249. The workload numbers provided in the new category, “Prepay and Postpay Medical Record Provider Specific Probe Review” were developed based on previous MR workload categories including Prepay Complex Reviews - Service and Provider Specific, Probe Reviews - Prepay and Postpay Complex - Provider and Services Specific, and Postpay Complex Reviews. CMS no longer requires Offerors to break out this workload by pre and post pay reviews when proposing its staffing plan in the BOE. The Medical Review (MR) One-on-One Education workloads were developed consistent with the One-on-One definition in IOM 100-8 Program Integrity Manual (PIM) Chapter 7.2.2.18 One-on-One Education and in the PIM Chapter 3.2.5 Targeted Probe and Educate (TPE). Further details for One-on-One Education as relates to the TPE is found in CR 10249 and CR 10963.

Further, the Offeror shall refer to TDL-180264 and TDL-190252 for specific direction on Computer Assisted Review of Documentation (CARD). For proposal purposes, Offerors shall comment on their use of CARD in their Medical Review operation.

22. MEDICARE HEALTHCARE PROVIDER INTERVENTION PROGRAM (MPIP)

The goal of this program is to educate providers/suppliers who are engaged in behavior that is potentially fraudulent, wasteful or abusive on proper claims billing practices in order to reduce the Medicare claims payment error rate. The JC MAC shall document all provider/supplier education interactions and shall monitor claims to evaluate the effectiveness of the MAC’s education efforts. If overpayment(s) are identified during the course of this program, the JC MAC shall adhere to the requirements in CMS IOM Publication 100-06, Medicare Financial Management Manual when recovering monies owed to Medicare and will notify the business owners of MPIP, the Division of Modeling and Analytics, of their intent to recover such monies.

The activities that Offerors will undertake within MPIP are the same as activities conducted in general MAC activities such as examining data related to payment errors and the education of providers on claims accuracy. After contract award, CMS will work with the MAC to develop and control the MPIP workload volumes. The Offeror shall prepare their proposal based on the annual workload assumptions provided in the chart below.

Table 5: MPIP Workload

23. SUPPORT FOR THE DME QIC DEMO (C.7.3)

The Offeror shall prepare their proposal based on the understanding that as a result of this demonstration ending in December 2020, any residual workload is expected to be nominal.

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