Amendment_Number_1_Attachment_1_to_Q As.docx

Amendment Number 1 Attachment 1

Below is a crosswalk of the BFCC-QIO 11th SOW Tasks, BFCC-QIO 11th SOW section C.7.1, the J-17 Attachment and the J-18B BFCC-QIO Business Proposal Forms

SOW - Task 1: Quality of Care Reviews

C.7.1 - Quality of care reviews, including beneficiary complaint reviews and general quality of care reviews;

J-17:

J-18B:

5. Quality of Care Reviews Cost Per Case 16. QOC Referrals

SOW - Task 2: Reviews of Beneficiary Appeals of Provider Discharges/Service Terminations and Denials of Hospital Admissions

C.7.1 - Beneficiary appeals of denials of hospital admissions, discharge and terminations of services decisions, commonly referred to as Grijalva, BIPA, and Weichardt appeals, etc.;

J-17:

6. Weichardt Appeals Cost Per Case 7. BIPA Appeals Cost Per Case 8. Grijalva Appeals Cost Per Case 12. Pre-Admission and Admission HINN

SOW - Task 3: Medical Necessity Reviews “Medical necessity review shall be conducted on all cases reviewed by the BFCC-QIO for any purpose, unless otherwise directed by CMS. The BFCC-QIO shall undertake medical necessity reviews in accordance with the appropriate chapter of the QIO Manual.”

C.7.1-Medical necessity reviews;

J-17:

Volume for this task was not included in the estimates since this work is a sub-part of the other reviews for which volume estimates were provided.

A separate form for this task was not included since this work is a sub-part of the other review categories.

SOW - Task 3: Medical Necessity Reviews “These reasonable and medically necessary reviews can include determinations about whether services and items proposed to be provided in a hospital or other health care facility on an inpatient basis could be effectively provided more economically on an outpatient basis or in an inpatient health care facility of a different type. “

C.7.1 - Appropriateness of setting reviews;

J-17:

Volume for this task was not included in the estimates since this work is a sub-part of the other reviews for which volume estimates were provided.

A separate form for this task was not included since this work is a sub-part of the other review categories.

SOW - Task 4: Higher Weighted Diagnosis-Related Group (HWDRG) Reviews

C.7.1 - Diagnosis Related Group (DRG) reviews;

J-17:

11. HWDRG Cost Per Case

SOW - Task 5: Readmission Reviews

C.7.1 - Readmission reviews;

J-17:

14. Non-Review Activities

SOW - Task 6: Focused Reviews These focused reviews are included in the other review types listed in the RFP.

C.7.1 – N/A

J-17:

N/A

N/A

SOW - Task 7: Emergency Medical Treatment and Labor Act (EMTALA)

C.7.1 - Reviews of Emergency Medical Treatment and Labor Act referrals (EMTALA);

J-17:

9. EMTALA: 5-day Reviews Cost Per Review 10. EMTALA: 60-day Reviews Cost Per Review

SOW - Task 8: Sanction Activities

C.7.1 - Sanctions; and

J-17:

Sanction Activities BFC11 Sanction Activities (3 Year Average)

13. Sanction Activities

SOW - Task 9: Recommendations for Quality Improvement Initiatives and Technical Assistance.

C.7.1 – N/A

J-17:

We did not provide estimates for this non-case review work.

SOW - Task 10: General Tasks

J-17:

We did not provide estimates for this non-case review work.

SOW - Task 11: Patient and Family Engagement This work will be drafted based on the results of the 10th SOW pilot and will be included as part of a Phase II amendment to the RFP. Only a general description has been included thus far.

C.7.1 – N/A

J-17:

N/A

N/A

SOW - Task 12: Discrimination Referrals

J-17:

We did not provide estimates for this non-case review work.

SOW - Task 10(d): General Tasks “Monitoring of Physician Acknowledgement Statements: Pursuant to 42 C.F.R. § 412.46, the BFCC-QIO shall conduct physician acknowledgement monitoring to ensure that each hospital has on file a physician acknowledgement statement for physicians billing for services provided in that hospital. The BFCC-QIO shall undertake this activity as directed in the appropriate chapter of the QIO Manual.”

C.7.1 - Monitoring of Physician Acknowledgement Statements under section 1156(a) of the Act and 42 CFR § 412.46.

J-17:

We did not provide estimates for this non-case review work.

J-18B: