Attachment 2 - J15 AB MAC Statement of Work.pdf

A/B MAC Statement of Work Jurisdiction 15 V.20.0

Part A and Part B Medicare Administrative Contractor Statement of Work

Last Revised: 10/18/2021

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C.1 Contents C.1 Scope

C.1.1 Purpose of Contract

C.1.2 Background

C.1.2.1 Medicare Part A

C.1.2.2 Medicare Part B

C.1.3 Contracting Reform

C.1.4 Roles and Responsibilities

C.1.4.1 The Centers for Medicare & Medicaid Services

C.1.4.1.1 Business Function Leads and Technical Monitors

C.1.4.2 Medicare Administrative Contractor (“The Contractor”)

C.1.4.3 Unique Requirements for the MAC

C.1.4.3.1 Unique Core Requirements

C.1.4.3.2 Jurisdiction-Specific Requirements

C.1.4.4 Home Health and Hospice Requirements

C.2 Applicable Documents

C.2.1 Statutes

C.2.1.1 Social Security Act (Public Law 74-271)

C.2.1.2 Medicare Prescription Drug, Improvement and Modernization Act (Public Law 108-173) 26

C.2.1.3 Health Insurance Portability and Accountability Act of 1996 (Public Law 104-191)

C.2.1.3.1 Administrative Simplification Compliance Act of 2002 (Public Law 107-105)

C.2.1.4 Tax Equity and Fiscal Responsibility Act of 1982 (Public Law 97-248)

C.2.1.5 Benefit Improvement and Protection Act of 2000 (Public Law 106-554)

C.2.1.6 Executive Order 13410

C.2.2 Regulations

C.2.3 Medicare Manuals

C.3 Key Definitions

C.4 Objectives

C.4.1 Customer Service

C.4.2 Operational Excellence

C.4.3 Innovation and Technology

C.4.4 Financial Management

C.4.5 A/B MAC Performance Standards

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C.5 Functional Requirements

C.5.1 Workload Implementation Requirements

C.5.1.1 Jurisdiction Implementation Project Plan

C.5.1.2 Reserved

C.5.1.3 Risk Management Plan

C.5.1.4 Cutover Plans

C.5.1.5 Test Plan

C.5.1.6 Lessons Learned Documentation

C.5.1.7 Accounts Receivable Reconciliation

C.5.1.8 Consolidation of Part A and Part B Edits

C.5.1.8.1 Consolidation of Reason Codes

C.5.1.9 Implementation Stakeholder Communication

C.5.1.10 Implementation Meetings

C.5.2 Workload Closeout Project Plan (Option that may be exercised at the End of the Contract) 34

C.5.2.1 Workload Closeout Project Plan (Option that may be exercised at the End of the Contract)

C.5.2.2 Workload Closeout Meetings (Option that may be exercised at the End of the Contract) 34

C.5.2.3 Workload Closeout Risk Management Plan (Option that may be exercised at the End of the Contract)

C.5.2.4 Accounts Receivable Reconciliation (Option that may be exercised at the End of the Contract) 35

C.5.2.5 Cost Accounting/Audit (Option that may be exercised at the End of the Contract)

C.5.2.6 Provider Cost Reports and Appeals (Option that may be exercised at the End of the Contract) 35

C.5.3 Infrastructure Requirements

C.5.3.1 Virtual Data Center

C.5.3.1.1 Local Hardware and Software Requirements

C.5.3.1.1.1 Translation Software

C.5.3.1.2 Reserved

C.5.3.2 Telecommunications

C.5.3.2.1 Telecommunications for Electronic Data Interchange

C.5.3.2.1.1 Electronic Data Interchange Enrollment Form

C.5.3.2.1.2 Transaction Error Reporting

C.5.3.2.1.3 Receipt of Electronic Data Interchange Transactions

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C.5.3.2.1.4 Sending Electronic Data Interchange Transactions

C.5.3.2.1.5 Automated Clearing House Transactions

C.5.3.2.1.6 Direct Data Entry Capability

C.5.3.2.1.7 Initial Edits

C.5.3.2.1.8 Combined Common Edits and Enhancement Module (CCEM) Software – Edits .. 43

C.5.3.2.2 Electronic Data Interchange Help Desk

C.5.3.2.3 Electronic Funds Transfer EFT Forms

C.5.3.2.4 HIPAA Code Set Updates

C.5.3.2.5 Claim Adjustment Reason Codes (CARC)/Remittance Advice Remark Code (RARC) .. 44

C.5.3.2.6 Reserved

C.5.3.3 Telephone Service

C.5.3.4 CMS Audits and Reviews

C.5.4 Administrative Requirements

C.5.4.1 Key Personnel

C.5.4.1.1 Project Manager

C.5.4.1.2 Claims Processing Manager

C.5.4.1.3 Chief Financial Officer

C.5.4.1.4 Compliance Officer

C.5.4.1.5 Provider Enrollment Manager

C.5.4.1.6 Chief Information Officer

C.5.4.1.7 Systems Security Officer

C.5.4.1.8 Implementation Project Director

C.5.4.1.9 Provider Customer Service Program Manager

C.5.4.1.10 Reserved (formerly Contract Administrator)

C.5.4.1.11 Executive Contractor Medical Director (CMD) and Supporting CMDs

C.5.4.1.12 Audit and Reimbursement Manager/Director

C.5.4.2 Reserved

C.5.4.2.1 Reserved

C.5.4.3 Security

A. Baseline Security Requirements

B. Training

C. Rules of Behavior

D. Incident Response

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E. Position Sensitivity Designations

F. Homeland Security Presidential Directive (HSPD)-12

G. Contract Initiation and Expiration

H. Records Management and Retention

I. Privacy Act

J. Security Requirements for GOCO and COCO Resources

K. HHS FedRAMP Privacy and Security Requirements

L. Protection of Information in a Cloud Environment

M. Security Assessment and Authorization (SA&A) Process

N. Reporting and Continuous Monitoring

O. Configuration Baseline

P. Incident Reporting

Q. Media Transport

R. Boundary Protection: Trusted Internet Connections (TIC)

S. Hardware Procurements

T. Non-Commercial and Open Source Computer Software Procurements

U. Information Technology Application Design, Development, or Support

C.5.4.3.1 Certification by Chief Information Officer for Compliance with CMS Systems Security Requirements

C.5.4.3.2 Administer Security Program

C.5.4.3.3 Access to Systems

C.5.4.3.3.1 Reserved

C.5.4.3.3.2 Other Systems Access Requirements

C.5.4.3.4 Correct Deficiencies

C.5.4.3.4.1 Corrective Action Attestation

C.5.4.3.5 Security Review and Verification

C.5.4.4 Quality Assurance Requirements

C.5.4.4.1 Quality Control Program

C.5.4.4.2 Reserved

C.5.4.4.3 Reserved

C.5.4.4.4 Reserved

C.5.4.5 Public Relations

C.5.4.5.1 Medicare Beneficiary Ombudsman

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C.5.4.5.2 Regional Office Liaison

C.5.4.5.2.1 Urgent Need Regional Office Casework

C.5.4.5.3 Responding to Complex Beneficiary Inquiries

C.5.4.5.3.1 Acceptance and Tracking of Complex Beneficiary Inquiry Referrals

C.5.4.5.3.2 English, Spanish, and Text Telephone Capabilities

C.5.4.5.3.3 Review Written Responses for Reading Level (Fogging) Accuracy and Timeliness77

C.5.4.5.3.4 Feedback

C.5.4.6 Congressional Inquiries

C.5.4.6.1 Responses to Congressional Inquiries

C.5.4.6.2 Congressional Outreach and Education

C.5.4.7 Participation in Conferences, Meetings, and Work Groups

C.5.4.7.1 Participation in Conferences

C.5.4.7.1.1 CMS Financial Management Training Conference

C.5.4.7.2 Trainings, Meetings, and Work Groups

C.5.4.7.3 Support Income Tax Reporting

C.5.4.8 Participation in Change Management Process

C.5.4.8.1 Review and Comment on Draft Change Requests

C.5.4.8.1.1 Level of Effort Assessments

C.5.4.8.2 Early Involvement

C.5.4.8.3 Successful Implementation of Change Requests

C.5.4.8.3.1 Walkthroughs

C.5.4.8.4 Participation in Testing Changes to Systems

C.5.4.8.5 Successful Post-Implementation Operation

C.5.4.9 Continuity of Operations Planning

C.5.4.10 Internal Controls

C.5.4.10.1 Written Policies and Procedures

C.5.4.10.2 Self-Assessment Process for Internal Controls

C.5.4.10.3 Correcting Internal Control Deficiencies – Corrective Action Plan Process

C.5.4.10.4 Statement on Standards for Attestation Engagements 18 (SSAE 18)

C.5.4.11 Compliance Program

C.5.4.12 Reserved

C.5.5 Provider Enrollment

C.5.5.1 Process Initial Enrollment and Revalidation Applications

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C.5.5.1.1 Process A/B Initial Enrollments

C.5.5.1.2 Process A/B Revalidations

C.5.5.1.3 Process Other Than A/B Initial Enrollments

C.5.5.2 Process Changes, Updates, Reassignments or Corrections

C.5.5.3 Revocations/Deactivations

C.5.5.4 Provider Enrollment Appeals

C.5.5.5 Maintain State-Specific Licensure/Certification Information

C.5.5.6 Participating Physician Enrollment

C.5.6 Local Coverage Determinations

C.5.6.1 Contractor Advisory Committee

C.5.6.2 LCD Development Process

C.5.6.2.1 Informal Meetings

C.5.6.2.2 New LCD Requests

C.5.6.2.3 Consultation

C.5.6.2.4 Open Meeting

C.5.6.2.5 LCD Reconsideration Process

C.5.6.3 LCD Content

C.5.6.3.1 Code(s) Relocation to Articles

C.5.6.3.2 Evidentiary Content

C.5.6.3.3 Response to Public Comments

C.5.6.3.4 Final LCD Decision

C.5.6.4 Transitioning LCDs

C.5.6.5 National Coverage Determination Implementation at the Local Level

C.5.7 Provider Customer Service Program

C.5.7.1 Provider Outreach and Education

C.5.7.1.1 Data Analysis

C.5.7.1.2 Provider Outreach and Education Advisory Group

C.5.7.1.3 “Ask-the-Contractor” Teleconferences

C.5.7.1.4 Provider Organization Partnerships

C.5.7.1.5 Promotion of Internal Communication and Development of Provider Education Needs 95

C.5.7.1.6 Bulletin/Newsletter Publication

C.5.7.1.7 Provider Service Plan

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C.5.7.1.8 Provider Customer Service Program (PCSP) Activity Report

C.5.7.1.9 Direct Mailings

C.5.7.2 Provider Contact Center

C.5.7.2.1 Telephone Inquiries

C.5.7.2.2 Written Inquiries

C.5.7.2.3 Provider Relations Research Specialists

C.5.7.2.3.1 Reserved

C.5.7.2.4 Inquiry Tracking System

C.5.7.3 Provider Self-Service Technology

C.5.7.3.1 Interactive Voice Response

C.5.7.3.2 Web Technology

C.5.7.3.3 Provider Electronic Mailing List

C.5.7.3.4 Reserved

C.5.7.3.5 Provider Internet Portal

C.5.7.4 Provider Customer Service Program Staff Training

C.5.8 Claims Processing

C.5.8.1 Standard Paper Remittance Advice Transactions

C.5.8.1.1 Direct Data Entry Support

C.5.8.2 General Claims Processing

C.5.8.2.1 Communication of Claims Processing Problems

C.5.8.2.2 Resolution of CWF Rejected Claims Involving another MAC

C.5.8.2.3 Resolution of Claims Transaction Replies from Common Working File

C.5.8.2.4 Resolution of Unsolicited Responses from Common Working File

C.5.8.2.4.1 MSP Claim with Complete Primary Payer Notification of Benefits Paid

C.5.8.2.4.2 Identification of Potential MSP Existence

C.5.8.2.5 Payment of Claims outside Common Working File

C.5.8.2.6 Handling of Medicare Advantage Claims

C.5.8.2.6.1 Medicare Advantage Claims for Hospice Care

C.5.8.2.6.2 Medicare Advantage Claims for National Coverage Decision or Legislative Change in Benefits 105

C.5.8.2.7 Local System Edits

C.5.8.3 Development of Suspended Claims

C.5.8.4 Back-End Processing

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C.5.8.4.1 Remittance Advice and Medicare Summary Notices

C.5.8.4.2 Coordination of Benefits Flat Files

C.5.8.4.3 Generate and Mail Claims Processing Documents

C.5.8.4.4 The Do Not Forward Initiative

C.5.8.5 Opt-Out Payment Provisions

C.5.8.6 Incentive Payments

C.5.8.6.1 Physician Incentive Payments for Services in HPSA and Physician Scarcity Area

C.5.8.6.2 Physician Quality Reporting System (formerly Physician Quality Reporting Initiative)

C.5.8.6.3 Electronic Prescribing Initiative

C.5.8.6.4 Primary Care Incentive Payment Program (PCIP)

C.5.8.6.5 Future Incentives as Mandated by Legislation

C.5.8.7 Participating Competitive Acquisition Program Physician Claims for Administering Part B Drugs 109

C.5.8.7.1 Listing of Competitive Acquisition Program Participating Physicians and Practitioners

C.5.8.7.2 Monitoring CAP Physicians and Practitioner Claims for Administering Part B Drugs

C.5.9 Reopening of Medicare Initial Claims Determinations

C.5.9.1 Reopening

C.5.9.1.1 Reopenings on the Contractor’s Own Motion

C.5.9.1.2 Reopenings on the Request of a Party

C.5.9.1.2.1 Clerical Error Reopenings

C.5.9.1.2.2 Documentation Requests

C.5.9.1.3 Reopening Appeal Cases

C.5.9.2 Establishing Good Cause for Reopening Initial Determinations and Redeterminations .. 111

C.5.9.3 Reopening Decisions

C.5.10 Appeals of Medicare Initial Claims Determinations

C.5.10.1 Redetermination Requests

C.5.10.1.1 Controlling Receipt of Correspondence

C.5.10.1.2 Document Imaging and Indexing

C.5.10.1.3 Acceptance of Valid Redetermination Requests

C.5.10.1.3.1 Confirmation of Receipt of Redetermination Requests

C.5.10.1.4 Misfiled Appeal Requests

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C.5.10.1.5 Granting of Extensions for Late Redetermination Requests and Determination of Good Cause 112

C.5.10.1.6 Consolidation of Multiple Requests for the Same Claim

C.5.10.1.7 Withdrawals and Eligibility-Based Dismissals

C.5.10.1.8 Assistance to Beneficiary

C.5.10.1.9 Conduct and Notice of the Redetermination

C.5.10.1.10 Documenting the Redetermination Case Files

C.5.10.1.11 Reserved

C.5.10.2 Appeal Decision Effectuation

C.5.10.3 Monthly Statistical Report on Reopening and Appeals Activities (CMS – 2592 & CMS 2590/2591) 115

C.5.10.4 Reserved

C.5.11 Financial Management of Trust Fund Dollars

C.5.11.1 Use of Trust Fund

C.5.11.1.1 Certification of Financial Reporting by Chief Financial Officer for Medicare Operations 116

C.5.11.1.2 Validation of Financial Data

C.5.11.1.3 Resolution of Financial Deficiencies

C.5.11.2 Banking Relations

C.5.11.2.1 Account Services Analysis

C.5.11.2.2 Benefits Account

C.5.11.2.3 Account Reconciliation

C.5.11.2.3.1 Cash Collections Worksheet

C.5.11.2.3.2 Estimated Allowance for Uncollectible Accounts

C.5.11.2.4 Letter-of-Credit Limitation

C.5.11.3 Cost Reporting and Reimbursement Payment Policy

C.5.11.3.1 The Medicare Cost Report

C.5.11.3.1.1 CMS Cost Report and Reimbursement Inquiries

C.5.11.3.2 Audit Activities of Institutional Provider Cost Reports

C.5.11.3.2.1 Cost Report Acceptance

C.5.11.3.2.1.1 Cost Report Reminder Letter

C.5.11.3.2.1.2 Cost Report Acceptance

C.5.11.3.2.1.3 Late Cost Reports

C.5.11.3.2.1.4 Rejected Cost Reports

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C.5.11.3.2.2 Tentative Settlements

C.5.11.3.2.3 Desk Reviews

C.5.11.3.2.3.1 Desk Reviews of Providers’ Cost Reports

C.5.11.3.2.3.2 Provider Permanent Files

C.5.11.3.2.4 Wage Index

C.5.11.3.2.5 Audits

C.5.11.3.2.5.1 Cost Report Audits

C.5.11.3.2.5.2 Audit Plan

C.5.11.3.2.5.3 Audits of Home Office Cost Statements

C.5.11.3.2.6 Final Settlement

C.5.11.3.2.7 Reopenings

C.5.11.3.2.7.1 Cost Report Reopenings

C.5.11.3.2.7.2 Reopening Notices or Denials

C.5.11.3.2.8 Appeals

C.5.11.3.2.8.1 Cost Report Appeals – Intermediary Appeal

C.5.11.3.2.8.2 Cost Report Appeals: Provider Reimbursement Review Board

C.5.11.3.2.8.3 Cost Report Appeals: Court Hearing / Settlements

C.5.11.3.2.8.4 Cost Report Appeals: Final Decisions

C.5.11.3.2.8.5 Requests for Cost Report, Audit and Reimbursement Information

C.5.11.3.2.9 Worksheet S-10 Audits

C.5.11.3.3 Provider Reimbursement

C.5.11.3.3.1 Institutional Provider Reimbursement

C.5.11.3.3.2 Provider-Specific File (PSF) Correctness

C.5.11.3.3.3 Hospice Cap

C.5.11.3.3.4 Target Limits: Tax Equity and Fiscal Responsibility Act

C.5.11.3.3.5 Exception Requests: End-Stage Renal Disease

C.5.11.3.3.6 Exception Requests: Tax Equity and Fiscal Responsibility Act

C.5.11.3.3.7 Special Payment Status

C.5.11.3.3.8 Institutional Provider Reimbursement – Reimbursement for FQHCs and RHCs126

C.5.11.3.3.9 Medicare Supplemental Payments for FQHCs under contract with Medicare Advantage Plans

C.5.11.3.4 Audit/Reimbursement Systems – File Maintenance

C.5.11.3.4.1 Provider Statistical and Reimbursement Report

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C.5.11.3.4.2 System for Tracking Audit and Reimbursement System

C.5.11.3.4.3 Interns and Residents Information System

C.5.11.3.4.4 Health Care Provider Cost Report Information System

C.5.11.3.5 Provider-Based Determinations

C.5.11.3.6 HITECH Incentive Payments resulting from the American Recovery and Reinvestment Act (ARRA) 127

C.5.11.3.6.1 Subsection (D) Hospitals

C.5.11.3.6.1.1 2552-96 Data

C.5.11.3.6.1.2 Subsection (d) Hospitals

C.5.11.3.6.1.3 Cost Report Accuracy

C.5.11.3.6.1.4 Audits

C.5.11.3.6.1.5 Final Settlements

C.5.11.3.6.2 Critical Access Hospitals

C.5.11.3.6.2.1 Requests for Additional Information

C.5.11.3.6.2.2 Allowable Amounts

C.5.11.3.6.2.3 Medicare Share Calculation

C.5.11.3.6.2.4 Medicare Share

C.5.11.3.6.2.5 Cost Report Accuracy

C.5.11.3.6.2.6 HITECH Data Elements

C.5.11.3.6.2.7 Final Payment Data

C.5.11.3.6.3 Time Tracking

C.5.11.3.7 Other Audit & Reimbursement Activities

C.5.11.3.7.1 Provider Change in Contractors

C.5.11.4 Non-Medicare Secondary Payer Overpayment

C.5.11.4.1 Recovery of Overpayments

C.5.11.4.2 Applications for Extended Repayment Schedule

C.5.11.4.3 Limitation on Recoupment (935) for Providers, Physicians and other Suppliers overpayments

C.5.11.4.4 Reserved

C.5.11.5 Non-Medicare Secondary Payer Debt Collection Activities

C.5.11.6 Non-Medicare Secondary Payer Debt Referral

C.5.11.6.1 Non-Medicare Secondary Payer Debt Collection Improvement Act Intent to Refer Letter 132

C.5.11.6.2 Non-Medicare Secondary Payer Debt Referral Inquiries

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C.5.11.6.3 Debt Collection System Database

C.5.11.6.4 Posting of Debts Collected by Treasury

C.5.11.6.5 Posting of Debts Returned to Agency (RTA) by Treasury

C.5.11.7 Refunds

C.5.11.7.1 Unsolicited/Voluntary Refunds

C.5.11.8 Overpayment Related to Bankruptcy

C.5.11.8.1 Administrative Freeze Payments

C.5.11.8.2 Closed Bankruptcy Case

C.5.11.9 Financial Reporting and Accounting

C.5.11.9.1 Accounts Receivable Trend Analyses

C.5.11.9.2 Financial Reporting Audits/Reviews

C.5.11.9.3 Other Financial System Controls

C.5.11.10 Medicare Credit Balance Report Activities

C.5.12 Medical Review

C.5.12.1 Development of Annual Improper Payment Reduction Strategy

C.5.12.1.1 Reserved

C.5.12.1.2 Medical Review Data: Edit Effectiveness

C.5.12.1.3 Reserved

C.5.12.1.4 Reserved

C.5.12.1.5 Medical Review of Claims

C.5.12.1.6 Defending Medical Review Decisions at Administrative Law Judge (ALJ) Hearings . 138

C.5.12.1.6.1 Coordination

C.5.12.1.6.2 Reserved

C.5.12.1.6.3 Reserved

C.5.12.1.6.4 Reserved

C.5.12.2 Medical Review Activity Definitions

C.5.12.2.1 Automated Medical Review

C.5.12.2.2 Non-Medical Record Review

C.5.12.2.3 Demand Bill Claims Review

C.5.12.2.4 Medical Review Reopening

C.5.12.2.5 Prepay Provider Specific Medical Record Review

C.5.12.2.6 Prepay Service Specific Medical Record Review

C.5.12.2.7 Prepay Provider Specific Probe Medical Record Review

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C.5.12.2.8 Prepay Service Specific Probe Medical Record Review

C.5.12.2.9 Advance Determination Medicare Coverage (ADMC)

C.5.12.2.10 Postpay Provider Specific Probe Medical Record Review

C.5.12.2.11 Postpay Service Specific Probe Medical Record Review

C.5.12.2.12 Postpay Provider Specific Medical Record Review

C.5.12.2.13 Postpay Service Specific Medical Record Review

C.5.12.2.14 Data Analysis

C.5.12.2.15 Reserved

C.5.12.2.16 Medical Review Edit Development

C.5.12.2.17 Externally Directed Reviews

C.5.12.2.18 Provider Compliance Group Directed Reviews

C.5.12.2.19 Monthly Reporting of Medical Review Savings

C.5.12.2.20 One on One Education

C.5.12.2.21 Prior Authorization for Certain Hospital Outpatient Department (OPD) Services . 142

C.5.12.2.22 Prior Authorization for Repetitive, Scheduled Non-Emergent Ambulance Transport

(RSNAT) 143

C.5.12.3 Portal Standards in Support of MR Functions

C.5.12.3.1 Secure Messaging/Mailbox

C.5.13 Coordination with UPICs

C.5.13.1 Support of Program Integrity

C.5.13.2 Support of Comprehensive Error Rate Testing

C.5.13.3 Support of Cost Report Audit Activities, Data Analysis and Special Projects

C.5.14 Medicare Secondary Payer

C.5.14.1 Implementation of Medicare Secondary Payer Operations

C.5.14.2 Electronic Correspondence Referral System Status Inquiries

C.5.14.3 Identification and Adjudication of MSP Claims and Application of Benefits and Processing Formula

C.5.14.3.1 Medicare Secondary Payer Claims Payment Determinations

C.5.14.3.2 Medicare Secondary Payer Claims Adjudication and Validation

C.5.14.3.3 Medicare Secondary Payer Claims Inquiries

C.5.14.3.4 MSP Claim with Complete EOB: Update CWF

C.5.14.3.5 Incomplete EOB: Possible MSP Claim, Possible MSP Situation, or CWF Exclusion:

Forward to BCRC

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C.5.14.4 Transfer of Documentation and Phone Calls to the Benefits Coordination and Recovery Center 148

C.5.14.5 Medicare Secondary Payer Hospital Audits

C.5.14.6 Medicare Secondary Payer Post Payment Recovery

C.5.14.6.1 Duplicate Primary Payments

C.5.14.6.2 Inquiries Specific to Debt Collection Efforts for Providers, Physicians and other Suppliers 150

C.5.14.6.3 Debt Collection Referral Activities for Providers, Physicians and other Suppliers ... 150

C.5.14.6.4 MSP Savings Report

C.5.14.6.5 Misrouted BCRC MSP Recovery Checks (Non-GHP) and/or Misrouted CRC MSP Recovery Checks (GHP)

C.5.14.6.6 Misrouted MSP Recovery Correspondence: Non-GHP and/or GHP

C.5.15 Provider Oversight

C.5.15.1 Review of Provider Billing Records

C.5.15.2 Review of Comprehensive Outpatient Rehabilitation Facility Billing Records

C.5.15.3 Review of IRF and CAH Rehabilitation Distinct Part Units

C.5.15.4 Conduct of Site Visits

C.5.16 Coordinated Care Benefits Demonstration (Notice of Enrollment) – (JK Only)

C.5.17 Reserved

C.5.18 Rural Health Clinics

C.5.18.1 Education Materials

C.5.19 Federally Qualified Health Centers

C.5.19.1 Education Materials

C.5.20 Foreign Claims

C.5.21 Reserved

C.5.22 Shipboard/Foreign Travel Services

C.5.23 Program Management Office

C.5.23.1 Post-Award Meeting

C.5.23.2 Project Management Plan

C.5.23.3 Reserved

C.5.23.4 Monthly Status Report and Operational Status Conference Calls

C.5.23.5 Ad Hoc Reporting

C.5.23.6 Voucher/Financial Management System

C.5.23.7 Reserved

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C.5.23.8 CROWD

C.5.23.9 ASCA Enforcement and Reporting

C.5.23.10 Freedom of Information Act Requests

C.5.23.11 Operational Productivity Report

C.5.24 Medicare Customer Experience (MCE)

C.5.25 Clinical Laboratory Fee Schedule – Gap-Fill Fees

C.5.26 Support of RAC Program Operations

C.5.26.1 Adjustment of RAC Selected Claims

C.5.26.2 Handling Underpayments and Overpayments identified by the RAC

C.5.26.3 Appeals of RAC Adjusted Claims

C.5.26.4 Reporting for RAC Program Support Operations

C.5.26.5 Other RAC Program Support activities

C.5.26.6 Reserved

C.5.27 Support and Coordination with Supplemental Medical Review Contractor (SMRC) Operations

C.5.27.1 Adjustment of SMRC Selected Claims

C.5.27.1.1 Collection of Overpayment

C.5.27.1.2 Recoupment Overpayment Tracking

C.5.27.2 Claim Reopenings

C.5.27.3 Voluntary Refunds

C.5.27.4 Provider Outreach and Education

C.5.27.5 Appeals

C.5.27.5.1 Redeterminations

C.5.27.5.2 Reconsiderations

C.5.27.5.3 Administrative Law Judge (ALJ) Hearings

C.5.27.5.4 Appeals Analysis

C.6 Interface Requirements

C.6.1 Successful Collaboration with Entities Requiring Joint Operating Agreements

C.6.1.1 Joint Operating Agreement: Quality Improvement Organization

C.6.1.1.1 Referrals to Quality Improvement Organization

C.6.1.1.2 Referrals from Quality Improvement Organization

C.6.1.1.2.1 Reserved

C.6.1.1.2.2 Billing Errors

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C.6.1.2 Joint Operating Agreement: Qualified Independent Contractor

C.6.1.2.1 Supply of Appeals Case Files

C.6.1.2.2 Reserved

C.6.1.2.3 Preparation of Case Files

C.6.1.3 Reserved

C.6.1.4 Joint Operating Agreement: Call Center Operations

C.6.1.5 Reserved

C.6.1.6 Reserved

C.6.1.7 Joint Operating Agreement: Cost Report Appeals Support Contractor

C.6.1.8 Joint Operating Agreement: Recovery Audit Contractor (RAC)

C.6.1.9 Joint Operating Agreement: Benefits Coordination and Recovery Center (BCRC)

C.6.1.10 Joint Operating Agreement: Audit Contractor

C.6.1.11 Joint Operating Agreement: Commercial Repayment Center (CRC)

C.6.1.12 Joint Operating Agreement: Supplemental Medical Review Contractor (SMRC)

C.6.1.13 Reserved

C.6.1.14 Joint Operating Agreement: Medical Review Accuracy Contractor (MRAC)

C.6.2 Successful Collaboration and Coordination with Other Internal and External Entities

C.6.2.1 State Agencies Responsible for Licensing Institutional Providers

C.6.2.2 Investigative Agencies

C.6.2.2.1 Access to Files, Records, Data, and Personnel

C.6.2.2.2 Search Warrants

C.6.2.3 CMS Field Offices

C.6.2.4 Medicare Advantage Plans, Prescription Drug Plans, and Nontraditional Fee-for-Service Entities 169

C.6.2.5 Other Medicare Administrative Contractors

C.6.2.5.1 Reserved

C.6.2.6 Professional Associations

C.6.2.7 Infrastructure Service Providers

C.6.2.8 Bank Interface

C.6.2.9 Benefits Coordination and Recovery Center (BCRC) – Non-Group Health Plan (NGHP/Non- GHP) Debts only

C.7 Jurisdiction-Specific Requirements

C.7.1 Reserved

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C.7.2 Reserved

C.7.3 Reserved

C.7.4 Reserved

C.7.5 Reserved

C.7.6 Reserved

C.7.7 Reserved

C.7.8 Reserved

C.7.9 Reserved

C.7.10 Reserved

C.7.11 Reserved

C.7.12 Reserved

C.7.13 Reserved

C.7.14 Reserved

C.7.15 Reserved

C.7.16 Reserved

C.7.17 Reserved

C.7.18 Reserved

C.7.19 Reserved

C.7.20 Reserved

C.7.21 Reserved

C.7.22 Reserved

C.7.23 Reserved

C.7.24 Reserved

C.7.25 Reserved

C.7.26 Reserved

C.7.27 Reserved

C.7.28 Reserved

C.7.29 Reserved

C.7.30 Reserved

C.7.31 Reserved

C.7.32 Reserved

C.7.33 Reserved

C.7.34 Reserved

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C.7.35 Reserved

C.7.36 Reserved

C.7.37 Reserved

C.7.38 Reserved

C.7.39 Reserved

C.7.40 Reserved

C.7.41 Reserved

C.7.42 Chair and Maintain FWG Calls (J15 and JM)

C.7.43 PECOS SME (J15)

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C.1 Scope The Contractor, as an independent Contractor and not as an agent of the government, shall furnish all the necessary services, qualified personnel, material, equipment, and facilities, not otherwise provided by the government, as needed to perform the work described in this Statement of Work (SOW).

The Contractor shall perform all Medicare Administrative Contractor (MAC) functions specified in this SOW and as further defined in either the Internet-Only-Manuals (IOMs, https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals- IOMs.html) or the Paper-Based Manuals, in accordance with Section C.2.3 of this SOW. For purposes of this contract, when differences or conflicts occur, this SOW shall take precedence over the IOMs and Paper-Based Manuals, unless otherwise specified. The Contractor shall contact the Contracting Officer (CO) and the Contracting Officer’s Representative (COR) if budgetary concerns occur because of this conflict. The Contractor is advised that any and all references in the SOW (including manuals, IOMs, etc.)

to “RO-Regional Office” shall be replaced with “CO-Contracting Officer” unless otherwise specified in this SOW. Appendix A contains definitions of all abbreviations used in this SOW.

C.1.1 Purpose of Contract The purpose of this contract is to obtain a Medicare Administrative Contractor (hereinafter, referred to as “the Contractor” or “MAC”) to provide specified health insurance benefit administration services, including Medicare claims processing and payment services, in support of the Medicare fee-for-service (FFS) program. The Contractor will perform its responsibilities under the direction of the Centers for Medicare & Medicaid Services (CMS).

Under this contract, the Contractor will perform numerous functions to support health care services for Medicare beneficiaries, which include performing claims-related activities and establishing relationships with providers of health care services, both institutional and professional, for a defined geographic area or “jurisdiction.” The Contractor will perform the requirements of this contract in accordance with applicable laws, regulations, Medicare manuals, and CMS requirements to ensure the financial integrity of the Medicare program. The Medicare program’s legal, policy, and operating environment is complex, and the Contractor will utilize or interact with certain CMS-required payment schedules, systems, equipment, and operational capabilities in the performance of its functions. Further, the Contractor will coordinate its activities not only with the CMS, but also with a broad range of agencies (at the federal, state, and local levels of government), other CMS partners and Contractors, and a diverse range of stakeholders within the health care system of the United States.

The Contractor will receive and control Medicare claims from institutional and professional providers, suppliers, and beneficiaries within its jurisdiction and will perform standard or required editing on these claims to determine whether the claims are complete and should be paid. In addition, the Contractor will calculate Medicare payment amounts and arrange for remittance of these payments to the appropriate party. The Contractor also will enroll new providers; conduct redeterminations on appeals of claims; operate a Provider Customer Service Program (PCSP) that educates providers about the Medicare program’s rules, regulations, and billing procedures; respond to provider electronic, telephone, and written inquiries; respond to complex inquiries from Call Center Operations (CCOs); and make coverage decisions for new procedures and devices in local areas.

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs.html https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs.html

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The Contractor shall furnish services to all the providers CMS designates as within the Contractor’s workload. The Contractor’s workload will, from time to time, contain out-of-jurisdiction providers. Out-of-jurisdiction providers will be moved to their destination workloads at a later date when CMS systems are capable of supporting the move.

The mission of CMS is to ensure health care security for beneficiaries. This contract specifically applies to that mission by fostering excellence in the design and administration of CMS’ programs.

C.1.2 Background The Medicare program is an integral component of the federal government’s commitment to the health and welfare of the American people, which includes the Social Security system, the Medicaid program (which is primarily administered by the states), and other programs. The Medicare program provides affordable health insurance to (1) eligible individuals aged 65 and over; (2) certain individuals eligible for disability benefits under the Social Security system; and (3) individuals with acute kidney failure (end-stage renal disease, or ESRD).

Nearly all Medicare beneficiaries may access their insurance benefits through one of two health care delivery systems:

First, in all areas of the country, a beneficiary may enroll in the traditional Medicare program (the Medicare FFS program) under which benefits are largely provided in keeping with an indemnity insurance model. That is, the beneficiary chooses his/her health care providers, the providers bill the appropriate Medicare claims administrator for their services, and the claims administrator pays the provider based on the eligibility, coverage, and payment rules of the Medicare Hospital Insurance (HI) and Supplementary Medical Insurance (SMI) programs. The federal government bears all financial (underwriting) risk for the cost of program benefits and develops detailed administrative requirements and processes to support the claim administration process. This national entitlement program has a strong imperative to provide a common level of benefits and service in all areas of the country, while maintaining adequate flexibility to account for local and regional medical practices.

Second, in many areas of the country, beneficiaries have the option to enroll in one or more privately sponsored Medicare plans under the Medicare Advantage (MA, formerly Medicare+ Choice) program.

These private Medicare plans may organize themselves in keeping with one of several health care delivery and payment models (health maintenance organizations, preferred provider organizations, etc.). These private Medicare plans are required to cover the same basic benefits that the traditional Medicare program offers, but they are given fairly broad responsibility and latitude to set up their internal requirements and processes as they see fit.

The Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA) included significant incentives to increase the participation in Medicare Advantage. However, for the next decade at least, the majority of all Medicare beneficiaries will likely remain enrolled in the traditional FFS Medicare program. FFS coverage in the Medicare program consists of two distinct parts: (1) HI, and (2) SMI, which provide coverage for the professional medical services of physicians and certain other licensed practitioners, as well as coverage for a variety of other services and items (ambulance, durable medical equipment, etc.). In common usage, the HI program is known as “Medicare Part A,” although both the Part A and B trust funds are used to reimburse institutional claims. The SMI program is known as “Medicare Part B;” only the Medicare Part B trust fund is used to reimburse Part B claims.

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C.1.2.1 Medicare Part A Services covered under Part A are: hospital inpatient services, skilled nursing facility (SNF) inpatient services, and swing bed services (SNF level in a rural hospital having less than 50 beds), hospice services, and some Home Health services. Institutional services paid under Part B include: hospital outpatient services, SNF outpatient services, all specialty facility services, such as dialysis for End Stage Renal Disease beneficiaries, outpatient rehabilitation services, regardless of the type of institution, and some Home Health services.

Nearly all Medicare beneficiaries are entitled to receive their Medicare Part A (HI) without payment of any insurance premium. Beneficiaries must elect to enroll in Medicare Part B (SMI), for which they must pay a monthly premium, and nearly all do so.

Under Medicare law, the Medicare HI (Part A) benefit is funded through the HI trust fund. The primary revenue source for the HI trust fund is a wage tax administered through the Social Security system. The HI trust fund accumulates a significant balance in excess of the amount needed for ongoing satisfaction of claims. The trustees of the HI trust fund include the Secretaries of the Treasury, Labor, and Health and Human Services. The Social Security Administration (SSA) Commissioner and two members of the public also serve as trustees of the HI trust fund.

C.1.2.2 Medicare Part B The Medicare SMI (Part B) benefit is administered through the SMI trust fund. Unlike the HI fund, however, the SMI trust fund does not accumulate a significant balance in excess of the amount needed for ongoing satisfaction of claims. In addition to receipts from beneficiary premiums, the primary revenue source for the SMI trust fund is an annual congressional appropriation from the Treasury’s general revenues. The trustees for the SMI trust fund are the same as those for the HI trust fund.

Medicare spending – both HI and SMI – is a substantial portion of the federal government’s annual budget and the health care economy of the United States.

The CMS relies on a network of contractors to process Medicare FFS claims; enroll health care providers in the Medicare FFS program and educate them on Medicare FFS billing requirements; handle claim appeals; and answer beneficiary and provider inquiries.

C.1.3 Contracting Reform On December 8, 2003, the President signed into law the MMA (Public Law 108-173). Section 911 of MMA directed the implementation of Medicare FFS Contracting Reform. Medicare Contracting Reform required that the CMS use competitive procedures to replace the prior Medicare FFS claims contractors (the FIs and carriers) with a uniform type of administrative entity, referred to as a MAC.

C.1.4 Roles and Responsibilities The roles and responsibilities of the parties are outlined below.

C.1.4.1 The Centers for Medicare & Medicaid Services The Medicare program’s authorizing statutes charge the Secretary of the Department of Health and Human Services (DHHS) with administrative responsibility for the Medicare program. The Secretary has delegated the program authority for Medicare (both the traditional FFS program and Medicare Advantage) to the CMS Administrator.

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The CMS administers the Medicare program, including formulation and promulgation of Medicare program policy and guidance, contract execution, operation and management, maintenance and review of utilization records, and general Medicare financing. The CMS is the largest purchaser of health care in the United States and provides health care coverage to nearly one in four Americans. The CMS’s annual budget places it among the largest payment operations in the world; its programs channel one out of every three dollars in the health care market, and its policies influence the other two dollars.

As part of its responsibility to administer the Medicare program, the CMS manages the work of the contractors engaged in its day-to-day operation. This management is accomplished through a variety of avenues such as periodic conferences on topics of general interest; targeted sessions with selected subsets of the contractors; issuance of manual updates describing changes in coverage, pricing, and eligibility; and evaluation of the performance of those contractors within the description of the work the CMS engages them to do.

C.1.4.1.1 Business Function Leads and Technical Monitors Within the CMS, specialists on various Medicare topics shall serve as Business Function Leads (BFLs) and Technical Monitors (TMs) to assist the COR and the CO in administering the contract. Through the COR, these BFLs/TMs shall provide technical guidance to the Contractor on matters within each BFL’s/TM’s area of responsibility. The BFL/TM shall consult with the COR on Technical Direction as necessary. The BFL/TM is not authorized to direct changes to contract work.

The MACs shall support the CMS field offices in their efforts to combat fraud, waste, or abuse and protect the Medicare Trust Fund.

C.1.4.2 Medicare Administrative Contractor (“The Contractor”) Section 1861 of the Social Security Act (“the Act”) defines the items and services for which Medicare may pay. It also defines the provider types recognized by the Medicare program. The Contractor is responsible for handling all the claims identified in the act, and related requirements identified in section C.5 and C.6 of this Statement of Work (SOW), that are within its jurisdiction, including claims from any out-of-jurisdiction providers assigned to the Contractor by CMS. The MAC is also responsible for processing Part A claims for Railroad Retirement Board Beneficiaries (RRB). To the extent provided in this SOW, the types of claims identified as additional services in Section C.7 are also mandatory jurisdiction-specific requirements under the contract.

The complexity of Medicare payment systems and policies and the numbers of contractors, providers, and insurers involved in the Medicare FFS program create vulnerabilities for error. To minimize these vulnerabilities and reduce the Medicare claims payment error rate, CMS has made paying claims right, the first time, one of its primary goals. This means paying the right amount, to legitimate providers, for Medicare-covered, reasonable and necessary services provided to eligible beneficiaries. Paying right the first time saves resources required to recover improper payments and ensures the proper expenditure of valuable Medicare trust fund dollars.

In the interest of consistency across the Medicare program, during the performance of this contract, the Contractor is expected to seek and follow advice from CMS on questions of law and policy as they arise.

Information relating to A/B MAC claims processing, information flows, interfaces and other supporting processes with “functional Contractors” can be found in both the Concept of Operations document

V.20.0 located at the following URL: http://www.cms.gov/Medicare/Medicare-Contracting/Medicare- Administrative-Contractors/Downloads/Functional-Contractors-Overview-2013.pdf and the A/B Claims Processing Enterprise Architecture which can be found at the following URL:

http://www.cms.gov/Medicare/Medicare-Contracting/Medicare-Administrative- Contractors/Downloads/A-B-Enterprise-Claims-Processing-Architecture.pdf

C.1.4.3 Unique Requirements for the MAC Under Title XVIII of the Social Security Act, the CMS contracted with individual fiscal intermediaries (FIs) and carriers to perform unique work and tasks beyond the base scope of the FI and Carrier contracts.

These special contract arrangements were for work that may have affected beneficiaries and/or providers in various states and/or regions.

C.1.4.3.1 Unique Core Requirements Under Medicare contracting reform, the CMS has decided to include some of these unique contract tasks within the core work requirements for each A/B MAC jurisdiction. Table 1 lists the activities that are incorporated into the core requirements for each A/B MAC jurisdiction.

Table 1 Unique Core Requirements

SOW Section Requirement C.5.17 Reserved C.5.18 Rural Health Clinics C.5.19 Federally Qualified Health Centers C.5.20 Foreign Claims C.5.21 Reserved C.5.22 Shipboard / Foreign Travel Services C.5.23 Program Management Office C.5.24 Medicare Customer Experience (MCE) C.5.25 Clinical Laboratory Fee Schedule - Gap-Fill Fees C.5.26 Support of Recovery Audit Contractor (RAC)

Operations C.5.27 Support and Coordination with Supplemental

Medical Review Contractor (SMRC) Operations All MAC Contractors should ensure they understand the impact to the functional requirements of these workloads.

C.1.4.3.2 Jurisdiction-Specific Requirements In addition to the requirements described in section C.1.4.3.1, the CMS has identified requirements for the MACs that are specific to a jurisdiction. Jurisdiction-Specific Requirements are located in Section C.7.

C.1.4.4 Home Health and Hospice Requirements Under Medicare Contracting Reform (MCR), CMS will assign the Medicare FFS health and hospice (HH+H) workload to four A/B MAC jurisdictions (6, M, K and 15). This HH+H workload will be grouped under four service areas. The service areas for HH+H are available on the CMS website at:

https://www.cms.gov/Medicare/Medicare-Contracting/Medicare-Administrative-Contractors/Who-are-the-MACs.html#ABandHH+H. NOTE: Each of these four A/B MAC contracts has some HH+H providers assigned to it on an out-of-jurisdiction basis.

http://www.cms.gov/Medicare/Medicare-Contracting/Medicare-Administrative-Contractors/Downloads/A-B-Enterprise-Claims-Processing-Architecture.pdf http://www.cms.gov/Medicare/Medicare-Contracting/Medicare-Administrative-Contractors/Downloads/A-B-Enterprise-Claims-Processing-Architecture.pdf https://www.cms.gov/Medicare/Medicare-Contracting/Medicare-Administrative-Contractors/Who-are-the-MACs.html#ABandHH+H https://www.cms.gov/Medicare/Medicare-Contracting/Medicare-Administrative-Contractors/Who-are-the-MACs.html#ABandHH+H

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Table 2 HH+H Jurisdiction Assignments

HH+H Service Area States Serviced A/B MAC Jurisdiction

A Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, & Vermont

K

B Colorado, Delaware, District of Columbia, Iowa, Kansas, Maryland, Missouri, Montana, Nebraska, North Dakota, Pennsylvania, South Dakota, Utah, Virginia, West Virginia, & Wyoming

C Alabama, Arkansas, Florida, Georgia, Illinois, Indiana, Kentucky, Louisiana, Mississippi, New Mexico, North Carolina, Ohio, Oklahoma, South Carolina, Tennessee, & Texas

M

D Alaska, American Samoa, Arizona, California, Guam, Hawaii, Idaho, Michigan, Minnesota, Nevada, New Jersey, New York, Northern Mariana Islands, Oregon, Puerto Rico, U.S. Virgin Islands, Wisconsin, & Washington

C.2 Applicable Documents The following statutes, regulations, manuals, and documents apply to this contract.

C.2.1 Statutes The Contractor must comply with all applicable laws. The major statute governing the Medicare program is Title XVIII of the Social Security Act (“the Act”), as amended. The Act and major amendments to the Act are outlined below (note: the list is not all inclusive). The identified amendments include legislation that significantly changed the Medicare program, are being implemented, or significantly affect the scope of work. Congress may pass new legislation at any time, and the Centers for Medicare & Medicaid Services (CMS) must act to implement such legislation as timely and accurately as possible.

C.2.1.1 Social Security Act (Public Law 74-271) The Act was enacted on August 14, 1935, with subsequent amendments. The Act consists of 21 titles, several of which have been repealed. The Hospital Insurance (HI) and Supplementary Medical Insurance (SMI) programs are authorized by Title XVIII of the Act. The vast bulk of the traditional Medicare FFS program’s authorizing law is codified in Parts A, B and E of Title XVIII. (Part C is primarily devoted to private Medicare plans, and Part D governs the Medicare prescription drug benefit.) Other Medicare-related authorizing statutes are in Titles II and XI of the Act; other governing provisions are in the Internal Revenue Code and other statutes.

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To the extent that there is no conflicting Medicare requirement, the administration of the traditional Medicare FFS program is also governed by numerous statutes pertaining to the general administration of federal programs. The following are among the general statutory authorities with broad implications for the traditional Medicare FFS program and the Medicare Administrative Contractor (MAC) contract:

a) Acquisition statutes (Competition in Contracting Act, etc.)

b) Financial management and internal controls (e.g., the Federal Managers’ Financial Integrity

Act of 1982 (FMFIA), the Chief Financial Officers’ Act of 1990, etc.)

c) Federal Information Security Management Act of 2014 (FISMA)

d) Government Performance and Results Act (GPRA)

e) Personnel and civil rights law (Drug-Free Workplace Act, Americans with Disability Act)

f) Privacy and information technology requirements (Privacy Act of 1974, Information

Technology Management Reform Act of 1996).

g) Rehabilitation Act of 1973 (including section 508, Accessibility Standards)

C.2.1.2 Medicare Prescription Drug, Improvement and Modernization Act (Public Law 108-173) On December 8, 2003, the President signed the Medicare Prescription Drug, Improvement and Modernization Act (MMA) into law. This statute made the most sweeping changes in the structure of the Medicare program since its inception in 1966. The significant changes made by this statute include the following:

a) Establishment of a temporary Medicare prescription drug discount card program.

b) Establishment of a permanent Medicare prescription drug program.

c) Renaming of the Medicare+Choice to Medicare Advantage and provision of significant new incentives to facilitate the participation of private plans in Medicare.

d) Provision of certain preventive benefits under both traditional Medicare and Medicare

Advantage.

e) Implementation of many changes in coverage and payment policy within traditional Medicare.

f) Implementation of many administrative and regulatory reforms within traditional Medicare.

g) Under Section 911 of the MMA, restructuring of the acquisition statutes that govern traditional

Medicare, commonly known as Medicare Contracting Reform. (see C.1.3 above).

h) Under Section 912 of the MMA, requirements for MAC information security programs and independent evaluations thereof.

i) Under Section 921 of the MMA, provision requiring toll-free lines for provider inquiries and an expansion of provider education.

The work under this contract will be affected by many of these provisions; however, the primary authority governing the terms and conditions of this contract is Section 911.

C.2.1.3 Health Insurance Portability and Accountability Act of 1996 (Public Law 104-191) The Health Insurance Portability and Accountability Act (HIPAA) was enacted on August 21, 1996. Title II, Subtitle F, of HIPAA gives the Department of Health and Human Services (DHHS) the authority to mandate the use of standards for the electronic exchange of health care data; to specify what medical and administrative code sets should be used within those standards; to require the use of national identification systems for health care patients, providers, payers (or plans), and employers (or sponsors);

V.20.0 and to specify the types of measures required to protect the security and privacy of personally identifiable health care information.

C.2.1.3.1 Administrative Simplification Compliance Act of 2002 (Public Law 107-105) The Administrative Simplification Compliance Act requires that providers of healthcare submit their claims to Medicare electronically, with limited exceptions, to qualify for payment.

C.2.1.4 Tax Equity and Fiscal Responsibility Act of 1982 (Public Law 97-248) The Tax Equity and Fiscal Responsibility Act (TEFRA) made Medicare the secondary payer for certain employees and dependents.

C.2.1.5 Benefit Improvement and Protection Act of 2000 (Public Law 106-554) Section 521 of the Benefit Improvement and Protection Act (BIPA) changed the Medicare appeals process to create a uniform procedure for handling all Medicare appeals (Parts A and B) and specified time frames for filing appeals and rendering decisions.

C.2.1.6 Executive Order 13410 To the extent applicable and practical, the MAC shall follow Executive Order 13410: Promoting Quality and Efficient Health Care in Federal Government Administered or Sponsored Health Care Programs. This Executive Order promotes the efficient delivery of quality health care through the use of health information technology, transparency regarding health care quality and price, and incentives to promote the widespread adoption of health information technology and quality of care. To support this mission, the MAC shall use recognized health information interoperability standards at the time of this contract, in all relevant information technology systems supported, in whole or in part, through this contract. This includes existing standards from the Health Information Technology Standards Panel (HITSP) that have been recognized by the Secretary of HHS. Specific information regarding the HITSP standards can be found at www.hitsp.org.

C.2.2 Regulations The Contractor must comply with all applicable federal regulations. Generally, Medicare regulations are located in Title 42 and 45 of the Code of Federal Regulations (CFR).

C.2.3 Medicare Manuals Medicare manuals (e.g., Internet-only manuals—IOMs) are CMS program instructions, day-to-day operating instructions, policies, and procedures that are based on statutes and regulations, guidelines, models, and directives. CMS program components, providers, Contractors, and state survey agencies use Medicare manuals to administer CMS programs. As CMS paper-based manuals are updated, the updated materials are published in the IOMs and eliminated from the paper-based manuals. As noted at C.1, in the event of any conflict, this SOW shall have precedence over the IOMs. Further, in the event of any conflict, the IOMs shall have precedence over the paper-based manuals. The CMS will continue this phase-out/phase-in process until all manual instructions are in the IOMs. The IOMs and paper-based manuals can be found at https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/index.

Citations in this SOW are generally to an IOM Publication (e.g., IOM Pub. XX). Paper-based manual citations are used only where necessary (indicated as CMS Pub. XX).

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/index