J.23 Government Provided Proposal Assumptions (GPPA) 03302022.docx

RFP # 75FCMC22R0002

Attachment J.23 – Government Provided Proposal Assumptions (GPPA)

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 B (JB) 8-12 months from receipt of proposals. JB includes the states of Illinois, Indiana, Kentucky, Michigan, Minnesota, Ohio, Wisconsin.

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 JB 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 JB. In addition, the breakdown of User Acceptance Testing (UAT) regions for JB mirrors the configuration (the same number and breakdown) of Production regions for JB.

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 Medicare System (VMS) and Common Working File (CWF) systems as well as the Virtual Data Center and the CWF host. The Offerors shall not propose any change to the number or configuration of CICS production or CICS UAT regions for the Implementation period. Offerors may propose an alternative approach to Implementation period simulation testing and claims history build-out as permitted by (and only as permitted by) the proposal submission instructions at RFP, L.14.5.3, Tab F.

Table 1: Implementation Cutover Dates

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

All workloads have been converted to HIGLAS; moreover, for proposal purposes, Offerors shall assume that the JB 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 timeframes in the chart above for proposal purposes. These timeframes are depicted in the timeline below:

Implementation and Base Periods:

CLIN 0001 – Implementation

CLIN 0002 – Base Period

Table 2: Periods of Performance (POPs)

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 containing the provider population for the specified jurisdiction. It is up to the Offeror to determine the workload appropriate for each type of provider/supplier outreach and education activity. There are no CMS-specified staffing or workload requirements, so the Offeror must develop their own strategy for how they can best service the provider populations identified. Based on its strategy, the Offeror shall complete Columns G, J, and L on the BOE (Attachment J.22). 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. The Offeror shall use the overall inquiries volumes when proposing hours and costs for the overall inquiries workloads.

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 BOE remains the same; however, a line item has been added to account for change requests (CRs) being implemented by the shared system maintainers using a Hybrid Agile approach. 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 121 of the draft CRs are issued in final for implementation and approximately 30 corrected CRs are issued annually. Annually, approximately 82 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.01) 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 B the Offeror shall assume 41,016 boxes of hard copy Medicare records located in the facilities listed in Table 4. 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 41,016 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 JB contractor, their file storage subcontractor, and the incoming JB 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 JB contract.

The Offeror shall also include in their proposal (CLINs 0002 – 0008) the ongoing costs of storing a total of 41,016 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 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

Retrievex, dba Access Information Management 109 Lakeside Ave.

Delano, PA 18220

Retrievex, dba Access Information Management 4200 Industrial Blvd.

Indianapolis, IN 46254

Retrievex, dba Access Information Management 2300 Nelson Miller Parkway Louisville, KY 40223 40,141

8. MANAGEMENT PAPER BILLS/CLAIMS

In the management of paper bills and claims addressed in section D.1.1.2.1 of the SOW (Attachment J.01), 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 section C.2.2.3 of the SOW (Attachment J.01), 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 SOW (Attachment J.01), 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 SOW (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).

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 JB MAC workload will be assigned to US Bank for their MAC Medicare Bank Account.

CMS does not provide 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. WEB PORTAL INQUIRIES TRANSACTIONS

For proposal purposes, CMS is providing the number of Web Portal Inquiries - Transactions Received and Web Portal Inquiries - Transactions Returned, as defined below. This information is being provided to assist Offerors as it demonstrates the portal activity in Jurisdiction B at this time.

Table 5: Web Portal Transactions

Web Portal Inquiries Transactions Received

· The total of queries performed through the portal, regardless of whether the query finds a matching record. This excludes activities related to login, registration, revocation, new access requests, and re-certifications.

4,303,945

Web Portal Inquiries Transactions Returned

· The total of queries performed through the portal that find a matching record. This excludes activities related to login, registration, revocation, new access requests, and re-certifications.

3,381,047

15. PROVIDER/SUPPLIER TELEPHONE INQUIRIES

For proposal purposes, CMS is providing CMS provided Attachment J.23.B, CSR-Handled Telephone Inquiries Tables, which shall be completed by all Offerors.

16. 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).

17. 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 (OCT 2020) only.

18. MEDICAL REVIEW WORKLOADS

Several MR workload subcategories and numbers provided in the BOE (Attachment J.22) have been developed based on CR 9809, CR 10249 and TDL 200514. The workload numbers provided are the four new combined categories: Prepay Provider-Specific MR *(Combines Prepay Provider-Specific Medical Record Review (MRR) and Prepay Provider--Specific Probe MRR Work); Postpay Provider-Specific MR *(Combines Postpay Provider-Specific Medical Record Review (MRR)and Postpay Provider-Specific Probe MRR Work); Prepay Service Specific MR *(Combines Prepay Service-Specific Medical Record Review (MRR) and Prepay Service-Specific Probe MRR Work) and Postpay Service Specific MR *(Combines Postpay Service-Specific Medical Record Review (MRR) and Postpay Service-Specific Probe MRR Work). The 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 it relates to the TPE are found in CR 10249 and CR 10963. CMS may direct Offerors to shift the focus of their medical review within the four combined categories as applicable, to meet environmental dynamics. These changes may result from a Public Health Emergency, agency policy changes, etc.

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.

19. PRIOR AUTHORIZATION (PA) PROCESS FOR CERTAIN DURABLE MEDICAL EQUIPMENT, PROSTHETICS, ORTHOTICS, AND SUPPLIES (DMEPOS) ITEMS CMS issued Final Rule; Prior Authorization Process for Certain Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (CMS -6050 -F) effective February 29, 2016, which established the prior authorization process as a condition of payment for certain DMEPOS items that are frequently subject to unnecessary use. CMS issued Final Rule; Master List of DMEPOS Items Potentially Subject to a Face-to-Face Encounter and Written Order Prior to Delivery and/or Prior Authorization Requirements (CMS – 1713 -F), effective January 1, 2020, which established one master list of items potentially subject to face-to-face and written orders prior to delivery and/or prior authorization requirements. CMS requires prior authorization as a condition of payment for selected power mobility devices (PMDs), pressure reducing support surfaces (PRSS), lower limb prosthetics (LLPs), and orthoses. CRs 9942, 10190, 10780, 11189, 11201, 11424, 11689, 12040, 12641, and 12639 provide specific direction on the prior authorization process of these items. The BOE, Attachment J.22, incudes workloads for this activity under SOW Work Breakdown Structure (WBS) section E.4.7 – Medical Review of Claims.

20. 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 JB 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 JB 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 6: MPIP Annual Workload

21. SUPPLEMENTARY PROGRAM MANAGEMENT (PM) AND MEDICARE INTEGRITY PROGRAM (MIP) ACTIVITIES CMS acknowledges that current MAC contracts include customized activities, not specifically identified within the SOW. For instance, these customized activities may be in place to assist the provider community or to achieve improper payment rate reductions. To the extent applicable, if such customized approaches are being proposed for this jurisdiction, CMS is requiring Offerors to document these customizations within their proposal in Tab F and in the BOE as directed.

22. NEW ATTACHMENTS ADDED TO RFP

CMS is providing CMS has added the following attachments to the RFP to be submitted by Offerors: 1) Proposal Self-Check Tool (Attachment J.21), 2) Historic & Proposed FTE, Hours & Gross Cost Instructions & Narrative (Attachment J.22.A) and 3) Historic & Proposed FTE, Hours & Gross Cost Worksheet (Attachment J.22.B). Offerors are required to fully complete all of these attachments in support of its overall proposal, both technical and business. Proposal accuracy and consistency across your technical proposal, business proposal, and Attachments J.22, J.22.A and J.22.B is very important to CMS. The Self-Check Tool, Attachment J.21, will be used by the Government to validate the accuracy of your data. Detailed instructions for completion of the new attachments are provided within the documents.

CMS is providing CMS also added Attachment J.31, Printing and Postage Costs Tables. Postage and printing costs are significant cost drivers for a MAC contract. An Offeror must use several assumptions when developing its proposed postage rates and printing costs, such as workload estimates for each category of printed material, including paper Medicare Summary Notices (MSNs), Standard Paper Remittance Advices (SPRs), and any other mail category, for example, provider enrollment-related correspondence. For proposal purposes, the Offeror must use its own historic baseline to then estimate the unit printing cost of each of these mail category workloads, and then apply assumptions for future postage rates to determine its total proposed postage and printing costs. Offerors must complete attachment J.31, in full, to provide the depth of information the Agency needs to evaluate the Offeror’s proposed postage and printing costs.

Note: The Offeror’s historic baseline (or other relevant data) and correlating description must support the Offeror’s proposed workload and costs for each table. CMS will review any variances between the Offeror’s historic baseline and description and the Offeror’s proposed workloads and costs for reasonability and realism.

23. HISTORICAL WORKLOADS AND THE PUBLIC HEALTH EMERGENCY (PHE)

As stated in Attachments J.22 (BOE) and J.22.A (Historic & Proposed FTE, Hours, & Gross Cost Instructions & Narrative) due to the PHE, historic data provided by Offerors, specifically for the most recent history, shall not be for any period after February 2020.

24. CMS REQUESTING ONLY ELECTRONIC PROPOSALS

Due to the Public Health Emergency (PHE), CMS is not requesting paper or compact disc (CD) proposal submissions. CMS is providing CMS has provided detailed instructions in section L.11 for Offerors to e-mail electronic proposals.

25. NON-MSP COVID-19 ACCELERATED AND ADVANCED PAYMENTS (CAAP) RECOUPMENTS

In TDL 220004, CMS provided instructions to MACs on recouping outstanding CAAP balances, one year from the date on which a provider or supplier received their CAAP, pursuant to the terms laid out in the Continuing Appropriations Act, 2021, and Other Extensions Act. The TDL instructed all MACs to start issuing repayment status letters to providers and suppliers with outstanding CAAP balances, starting on or around October 18, 2021. For proposal purposes, CMS has escalated the Base Year Non-MSP Overpayment Demand Letter workloads to accommodate the CAAP demand letter activity.

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