HHSM-500-2015-RFP-0113_Amend_00001.pdf

HHSM-500-2015-RFP-0113

SOLICITATION, OFFER AND AWARD

4. TYPE OF SOLICITATION2. CONTRACT NUMBER 3. SOLICITATION NUMBER

7. ISSUED BY CODE 8. ADDRESS OFFER TO (If other than Item 7)

ORDER UNDER DPAS (15 CFR 700)

6. REQUISITION/PURCHASE NUMBER

NOTE: In sealed bid solicitations "offer" and "offeror" mean "bid" and "bidder".

NEGOTIATED (RFP)

SEALED BID (IFB)

5. DATE ISSUED

1. THIS CONTRACT IS A RATED RATING PAGE OF PAGES

1 77

C. E-MAIL ADDRESS

EXT.NUMBERAREA CODE

B. TELEPHONE (NO COLLECT CALLS)A. NAME

10. FOR

INFORMATION

CALL:

CAUTION: LATE Submissions, Modifications, and Withdrawals: See Section L, Provision No. 52.214-7 or 52.215-1. All offers are subject to all terms and conditions contained in this solicitation.

(Date)(Hour) local timeuntildepository located in copies for furnishing the supplies or services in the Schedule will be received at the place specified in Item 8, or if hand carried, in the

SOLICITATION

9. Sealed offers in original and

PART IV - REPRESENTATIONS AND INSTRUCTIONS

OTHER STATEMENTS OF OFFERORS

EVALUATION FACTORS FOR AWARD

INSTRS., CONDS., AND NOTICES TO OFFERORS

REPRESENTATIONS, CERTIFICATIONS AND

LIST OF ATTACHMENTS

CONTRACT CLAUSES

PART III - LIST OF DOCUMENTS, EXHIBITS AND OTHER ATTACH.

I

J

K

L

M SPECIAL CONTRACT REQUIREMENTS

CONTRACT ADMINISTRATION DATA

DELIVERIES OR PERFORMANCE

INSPECTION AND ACCEPTANCE

PACKAGING AND MARKING

DESCRIPTION/SPECS./WORK STATEMENT

SUPPLIES OR SERVICES AND PRICES/COSTS

SOLICITATION/CONTRACT FORM

PART II - CONTRACT CLAUSESPART I - THE SCHEDULE

H

G

F

E

D

C

B

A

SEC. DESCRIPTION PAGE(S) (X) DESCRIPTION SEC. (X)

11. TABLE OF CONTENTS

18. OFFER DATE17. SIGNATURE

SUCH ADDRESS IN SCHEDULE.

IS DIFFERENT FROM ABOVE - ENTER

15C. CHECK IF REMITTANCE ADDRESS

EXT.NUMBERAREA CODE

15B. TELEPHONE NUMBER

(Type or print)AND

ADDRESS

OF

OFFEROR

CODE FACILITY

16. NAME AND TITLE OF PERSON AUTHORIZED TO SIGN OFFER15A. NAME

DATEAMENDMENT NO.DATEAMENDMENT NO.

and related documents numbered and dated):

amendments to the SOLICITATION for offerors

(The offeror acknowledges receipt of

14. ACKNOWLEDGEMENT OF AMENDMENTS

CALENDAR DAYS (%)30 CALENDAR DAYS (%)20 CALENDAR DAYS (%)10 CALENDAR DAYS (%)

(See Section I, Clause No. 52.232.8)

13. DISCOUNT FOR PROMPT PAYMENT

designated point(s), within the time specified in the schedule.

by the offeror) from the date for receipt of offers specified above, to furnish any or all items upon which prices are offered at the price set opposite each item, delivered at the

12. In compliance with the above, the undersigned agrees, if this offer is accepted within ______________ calendar days (60 calendar days unless a different period is inserted

NOTE: Item 12 does not apply if the solicitation includes the provisions at 52.214-16, Minimum Bid Acceptance Period.

OFFER (Must be fully completed by offeror)

IMPORTANT - Award will be made on this Form, or on Standard Form 26, or by other authorized official written notice.

28. AWARD DATE

(Signature of Contracting Officer)

27. UNITED STATES OF AMERICA

25. PAYMENT WILL BE MADE BY

26. NAME OF CONTRACTING OFFICER (Type or print)

CODE 24. ADMINISTERED BY (If other than Item 7)

ITEM

(4 copies unless otherwise specified)

23. SUBMIT INVOICES TO ADDRESS SHOWN IN

41 U.S.C. 253 (c) ( 10 U.S.C. 2304 (c) (

22. AUTHORITY FOR USING OTHER THAN FULL AND OPEN COMPETITION:

21. ACCOUNTING AND APPROPRIATION20. AMOUNT19. ACCEPTED AS TO ITEMS NUMBERED

AWARD (To be completed by government)

CODE

05/06/2015 X

ASG - DPIFMC

CMS,OAGM,ASG,DPIFMC

7500 SECURITY BLVD., MS: B3-30-03

BALTIMORE MD 21244-1850

1130 ES 06/08/2015

Eisha Banks 410 eisha.banks@cms.hhs.gov

786-5145

X

X

X

X

X

X

X

X

X

X

X

X

X

PAGE(S)

THERESA A. SCHULTZ

AUTHORIZED FOR LOCAL REPRODUCTION

Previous edition is unusable

STANDARD FORM 33 (Rev. 9-97)

Prescribed by GSA - FAR (48 CFR) 53.214(c)

6-7

11-13 14-22 23-37

38-50

52-57

58-72

73-77

ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT

NAME OF OFFEROR OR CONTRACTOR

2 77

CONTINUATION SHEET

REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF

HHSM-500-2015-RFP-0113

(A) (B) (C) (D) (E) (F)

Period of Performance: 09/15/2015 to 09/14/2020

OPTIONAL FORM 336 (4-86)

Sponsored by GSA

FAR (48 CFR) 53.110

NSN 7540-01-152-8067

HHSM-500-2015-RFP-0113 Medical Claims Review for Managed Care Organizations

TABLE OF CONTENTS

PART I - THE SCHEDULE

SECTION B - SUPPLIES OR SERVICES AND PRICES/COSTS

B.1 Description of Services B.2 Schedule of Services B.3 Payment Schedule

SECTION C - DESCRIPTION/SPECIFICATIONS/WORK STATEMENT

C.1 Statement of Work

SECTION D - PACKAGING AND MARKING

D.1 Deliverables

SECTION E - INSPECTION AND ACCEPTANCE

E.1 FAR 52.252-2 Clauses Incorporated by Reference (FEB 1998) E.2 Inspection and Acceptance (MAY 2013) E.3 Acceptance by the Contracting Officer’s Representative (COR)

SECTION F - DELIVERIES OR PERFORMANCE

F.1 52.252-2 Clauses Incorporated By Reference (FEB 1998) F.2 Period of Performance F.3 Items to be Furnished and Delivery Schedule

SECTION G - CONTRACT ADMINISTRATION DATA

G.1 Accounting and Appropriation Data G.2 Payments – Invoices - Firm Fixed Price Contracts (AUG 2013) G.3 Contracting Officer’s Representative (COR) G.4 Technical Direction G.5 Contracting Officer Responsibility G.6 Correspondence Procedures G.7 Service of Consultants/Subcontractors G.8 Subcontract Consent G.9 Dissemination, Publication and Distribution of Information G.10 Data to be Delivered G.11 Contractor Past Performance Evaluation(s) (OCT 2014)

SECTION H - SPECIAL CONTRACT REQUIREMENTS

H.1 Organizational Conflict of Interest

HHSM-500-2015-RFP-0113 Medical Claims Review for Managed Care Organizations

H.2 HIPAA Business Associate Clause (OCT 2014) H.3 Security Clause-Background-Investigation for Contractor Personnel H.4 Revoking System Access upon Employee Departure H.5 CMS Information Security (APR 2013) H.6 HHSAR 352.242.70 Key Personnel (JAN 2006)

PART II - CONTRACT CLAUSES

SECTION I - CONTRACT CLAUSES

I.1 FAR 52.252-2 Clauses Incorporated By Reference (FEB 1998) I.2 Department of Health and Human Services Acquisition Regulations (HHASR)

Clauses Incorporated by Reference I.3 FAR 52.204-15 Service Contract Reporting Requirements for Indefinite-Delivery

Contracts (JAN 2014) I.3 FAR 52.204-19 Incorporation by Reference of Representations and Certifications

(DEC 2014)

I.4 FAR 52.204-19 Incorporation by Reference of Representations and Certifications (DEC 2014)

I.5 FAR 52.216-18 Ordering (OCT 1995) I.6 FAR 52.216-19 Order Limitations (OCT 1995) I.7 FAR 52.216-21 Requirements (OCT 1995) I.8 FAR 52.217-8 Option to Extend Services (NOV 1999) I.9 FAR 52.217-9 Option to Extend the Term of the Contract (MAR 2000) I.10 FAR 52.222-42 Statement of Equivalent Rates for Federal Hires (MAY 2014) I.11 FAR 52.252-6 Authorized Deviations in Clauses (Apr 1984) I.12 HHSAR 352.239-70 Standard for Security Configurations (January 2010) I.13 HHSAR 352.239-72 Security Requirements for Federal Information Technology

Resources (JAN 2010) I.14 HHSAR 352.239-73 Electronic and Information Technology Accessibility (JAN 2010)

PART III – LIST OF DOCUMENTS, EXHIBITS, AND OTHER ATTACHMENTS

SECTION J - LIST OF ATTACHMENTS

J.1 Medical Claims Review of Managed Care Organizations (MCOs) Statement of

Work (SOW) J.1.a Appendix A Schedule of Deliverables J.1.b Appendix B Sampl & Extrap Guidance J.1.c Appendix C MCO Standard Sampling Plan J.1.d Appendix D Extrapolation Template J.1.e Appendix E Cost Report Instructions 2013 J.1.f Appendix F Final Cost Report 2013 J.1.g Appendix G Overall Review Timeline J.1.h Appendix H Medical Coding Review Steps J.2 Wage Determination (To be included at award) J.3 Subcontract Checklist J.4 Virus Detection Certification

HHSM-500-2015-RFP-0113 Medical Claims Review for Managed Care Organizations

J.5 Responsibility Questionnaire J.6 Past Performance Questionnaire

SECTION J – LIST OF EXHIBITS

E.1 Prime Proposal Checklist E.2 Subcontractor Proposal Checklist E.3 Business Proposal Spreadsheet E.4 Medical Review of MCO Questions Template

PART IV - REPRESENTATIONS AND INSTRUCTIONS

SECTION K – REPRESENTATIONS, CERTIFICATIONS, AND OTHER STATEMENTS OF

OFFERORS OR RESPONDENTS

K.1 FAR 52.252-1 Solicitation Provisions Incorporated By Reference (FEB 1998) K.2 FAR 52.204-8 Annual Representations and Certifications (DEC 2014) K.3 FAR 52.209-7 Information Regarding Responsibility Matters (JUL 2013)

SECTION L – INSTRUCTIONS, CONDITIONS, AND NOTICES TO OFFERORS OR

RESPONDENTS

L.1 Procurement Timeline L.2 Department of Health and Human Services Acquisition Regulations (HHASR)

Provisions Incorporated by Reference L.3 FAR 52.215-1 Instructions to Offerors - Competitive Acquisition (JAN 2004)

Deviation L.4 FAR 52.216-1 Type of Contract (APR 1984) L.5 FAR 52.233-2 Service of Protest (SEP 2006) L.6 FAR 52.252-5 Authorized Deviations in Provisions (APR 1984) L.7 Communications Prior to Contract Award L.8 General Instructions L.9 Proposal Organization L.10 Volume I - Technical Proposal Instructions

L.11 Volume II - Business Proposal Instructions L.12 Volume III - Conflict of Interest Instructions

SECTION M – EVALUATION FACTORS FOR AWARD

M.1 FAR 52.217-5 Evaluation of Options (JUL 1990) M.2 General Procedures for Award

M.3 Technical Proposal Evaluation M.4 Business Proposal Evaluation M.5 Evaluation of Conflict of Interest

HHSM-500-2015-RFP-0113 Medical Claims Review for Managed Care Organizations

SECTION B – SUPPLIES OR SERVICES AND PRICES/COSTS

B.1 Description of Services

To initiate and procure the award of an Indefinite Delivery (ID) Requirements contract with fixed-price task orders for the medical coding and claims review of cost-based Managed Care Organizations (MCOs). The contractor shall assist CMS in determining the accuracy of medical costs and statistics on the final annual cost report, and to identify overpayments related to improper medical coding and/or insufficient medical documentation.

B.2 Schedule of Services

CLIN- Description Estimated Quantity FFP Per Claim Estimated Total

CLIN 0001- Claim Review Base Period

4,550

CLIN 0002 – Travel Base Period Not-to-Exceed $40,000.00 CLIN 1001- Claim Review Option Year 1

5,600

CLIN 1002 – Travel Option Year 1

Not-to-Exceed $40,000.00

CLIN 2001- Claim Review Option Year 2

7,350

CLIN 2002 – Travel Option Year 2

CLIN 3001- Claim Review Option Year 3

5,250

CLIN 3002 – Travel Option Year 3

CLIN 4001- Claim Review Option Year 4

6,650

CLIN 4002 – Travel Option Year 4

TOTAL 29,400

Please note that the quantities of supplies or services specified in the Schedule are estimates only and are not purchased by this contract. Except as this contract may otherwise provide, if the Government’s requirements do not result in orders in the quantities described as “estimated’’ or “maximum” in the Schedule, that fact shall not constitute the basis for an equitable price adjustment.

Task Orders: A task order will be issued against the Indefinite Delivery Requirements contract using a subCLIN for each Managed Care Organization (MCO) and the number of claims to be reviewed. If the MCO has multiple years, they will be separately listed. For example, Task Order 0001 is issued for the medical review of claims for three different MCOs:

HHSM-500-2015-RFP-0113 Medical Claims Review for Managed Care Organizations subCLIN MCO

Number of Claims

Fixed Price Per Claim Total

0001AA

XYZ Corp, #123 Year 2012 - 2013 700 $50.00 $35,000.00

0001AB

ABC Inc, #222 Year 2013 350 $50.00 $17,500.00

0001AC

TTT LLC, #555

Year 2012 - 2014 1,000 $50.00 $50,000.00

0002 Travel NTE $40,000.00

GRAND TOTAL $142,500.00

For each subCLIN the contractor will be paid against the total subCLIN price based on the payment schedule in Section B.3.

Example:

SubCLIN

MCO

Contract

Year Plan Name

Installment Payment #1:

Upon COR approval of

Project Management

Plan 10%

Installment Payment #2:

Upon COR approval of Sampling

Plan 15%

Installment Payment #3:

Upon completion of Fieldwork and

Preliminary List of Exceptions Submitted to

MCO

25%

Installment Payment #4:

Upon COR

Approval of each Draft Report

30%

Installment Payment #5:

Upon COR approval of each Final Report with

ALL work-papers Submitted

20%

Total Amount

0001AB 222 2013

ABC,

Inc. $1,750.00 $ 2,625.00 $4,375.00 $ 5,250.00 $3,500.00 $17,500.00

B.3 Payment Schedule

Sub CLINs

MCO

Contract

Year Plan Name

Installment Payment #1:

Upon COR approval of

Project Management

Plan

Installment Payment #2:

Upon COR approval of

Sampling Plan

Installment Payment #3: Upon completion of Fieldwork and

Preliminary List of Exceptions

Submitted to

MCO

Installment Payment #4:

Upon COR Approval of each Draft

Report

Installment Payment #5:

Upon COR approval of each Final

Report with ALL work-papers Submitted

Total Amount

10% 15% 25% 30% 20%

[END OF SECTION]

HHSM-500-2015-RFP-0113 Medical Claims Review for Managed Care Organizations

SECTION C – DESCRIPTION/SPECIFICATIONS/WORK STATEMENT

C.1 Statement of Work

Independently and as an agent of the Government, the Contractor shall furnish all the necessary services, qualified personnel, material, equipment, and facilities, not otherwise provided by the Government, as needed to perform the Statement of Work (SOW) as identified in Section J, Attachment J.1, entitled “Medical Claims Review of MCOs Statement of Work,” attached hereto and made a part of this solicitation.

HHSM-500-2015-RFP-0113 Medical Claims Review for Managed Care Organizations

SECTION D - PACKAGING AND MARKING

D.1 Deliverables

Deliverables shall be marked in accordance with the contract Section G.8, Correspondence Procedures, and Section J, Attachment J.1, entitled “Medical Claims Review for MCOs Statement of Work,” Appendix A, Items to be Furnished and Deliverables Schedule.

HHSM-500-2015-RFP-0113 Medical Claims Review for Managed Care Organizations

SECTION E – INSPECTION AND ACCEPTANCE

E.1 FAR 52.252-2 Clauses Incorporated By Reference (FEB 1998)

This contract incorporates one or more clauses by reference, with the same force and effect as if they were given in full text. Upon request, the Contracting Officer will make their full text available. Also, the full text of a clause may be accessed electronically at this address:

http://www.acquisition.gov/far/

Clause No. Title Date 52.246-4 Inspection of Services -- Fixed-Price AUG 1996

E.2 Inspection and Acceptance (MAY 2013)

Inspection and acceptance of the Contractor’s supplies or services shall be in accordance with the applicable FAR Clause in Section E.1 above.

All work under this contract is subject to inspection and final acceptance by the Contracting Officer, or the Contracting Officer’s Representative (COR), a duly authorized representative of the Contracting Officer. The COR is hereby delegated responsibility for inspection and acceptance of all supplies and services to be delivered under this contract.

E.3 Acceptance by the Contracting Officer’s Representative (COR)

All items to be delivered to the Contracting Officer’s Representative (COR) who will be deemed to have been accepted 60 calendar days after the date of delivery, except as otherwise specified in this contract if written approval or disapproval has not been given within such period. The COR’s acceptance or revision to the items submitted shall be within the general scope of the work stated in this contract.

http://www.acquisition.gov/far/

HHSM-500-2015-RFP-0113 Medical Claims Review for Managed Care Organizations

SECTION F – DELIVERIES OR PERFORMANCE

F.1 FAR 52.252-2 Clauses Incorporated By Reference (FEB 1998)

This contract incorporates one or more clauses by reference with the same force and effect as if they were given in full text. Upon request, the Contracting Officer will make their full text available. Also, the full text of a clause may be accessed electronically at this address:

http://farsite.hill.af.mil

Clause No. Title Date

52.242-15 STOP WORK ORDER AUG 1989

52.242-17 GOVERNMENT DELAY OF WORK APR 1984

52.247-34 F.O.B. DESTINATION NOV 1991

F.2 Period of Performance

The period of performance of this contract is 09/15/2015 through 9/14/2020.

This contract includes the following Option Periods:

Base Year – 9/15/2015 through 9/14/2016 Option Year 1 – 9/15/2016 through 9/14/2017 Option Year 2 – 9/15/2017 through 9/14/2018 Option Year 3 – 9/15/2018 through 9/14/2019 Option Year 4 – 9/15/2019 through 9/14/2020

F.3 Items to be Furnished and Delivery Schedule

The Contractor shall submit all required reports and deliverables in accordance with the following schedule. Reports and/or deliverables submitted under this contract shall be in accordance with the Statement of Work. All deliverables shall be submitted via email to the assigned Contracting Officer’s Representative (COR) and/or Servicing Auditor) or as indicated otherwise below.

Deliverable/ Conference Type Due Date Recipient

Required Claims Database Fields (SOW – Section IV.G.b.) 15 calendar days after contract award CAC, copying COR Planning Meeting - With each Cost Audit Contractor (CAC) (SOW – Section IV.G.a.) 15 calendar days after contract award

Between MRC and

CAC

Planning Meeting Minutes (SOW

– Section IV.G.a.) 3 calendar days after planning meeting COR

Kick-off Meeting Agenda (SOW

– Section IV.A.d.) 2 business days prior to the kick-off meeting COR

Kick-off Meeting with CMS (SOW – Section IV.A.d.) 20 calendar days after contract award

COR and Servicing Auditors http://farsite.hill.af.mil/

HHSM-500-2015-RFP-0113 Medical Claims Review for Managed Care Organizations

Kick-off Meeting Minutes (SOW

– Section IV.A.d.) 3 business days after Kick-off Meeting COR

Security and Tracking Plan – Draft (SOW – Section IV.A.f.) 20 calendar days after contract award COR Project Management Plan (PMP) – Draft (SOW – Section IV.A.e.) 20 calendar days after contract award COR PMP and Security and Tracking Plan – Final (SOW – Section IV.A.e.) 5 calendar days after approval of draft COR

Memo of Understanding Template (SOW – Section IV.C.a) 30 calendar days after contract award COR

Biweekly Status Report (SOW – Section V.F.) 1 calendar days prior to the biweekly call

COR and Servicing Auditors

Biweekly Status Call (SOW – Section V.F.) Biweekly – to be coordinated with the COR

COR and Servicing Auditors

Monthly Status Report (SOW – Section V.G.)

20 calendar days following the close of the reported month

COR and Servicing Auditors

Entrance Conference (SOW Section IV.G.c.) Within 120 days of contract award

To be coordinated with the CAC. CMS

COR to attend.

Sampling Plan – Separate for each MCO to be reviewed (SOW

– Section IV.B.b.)

Within 2 weeks of receiving the reconciled database.

COR, CAC and to each MCO Servicing

Auditor

Sample Selection sent to MCO (SOW – Section IV.B.c.)

10 calendar days after the sampling plan is approved. MCO

Mid-Contract Presentation (SOW

– Section V.H.)

As coordinated with CMS, within 7 months after contract award. Materials to be submitted 5 calendar days prior to the presentation.

COR, in-person presentation

Preliminary List of Exceptions sent to MCO and Preliminary Exit Conference to occur (SOW – Section IV.C.c.)

60 calendar days after the samples submitted to the MCO (60 calendar days after entrance conference) MCO, copy COR

Draft Report (SOW – Section V.D.)

30 calendar days after the medical record submission window is complete (60 calendar days after preliminary Exit Conference)

COR, Servicing Auditor, CAC

Final List of Exceptions (SOW – Section IV.C.c.)

30 calendar days after the medical record submission window is complete (60 calendar days after preliminary Exit Conference) MCO, copy COR

Final Exit Conference to occur (SOW Section IV.G.c.)

Within 120 days of Preliminary Exit Conference N/A

Final Report (SOW – Section V.E.)

5 calendar days after CMS approval of the draft report

COR, Servicing Auditor and CAC

Formal Reply to Plan Disagreements to Findings (SOW – Section IV.G.b.) Within 1 week of receiving disagreements.

CAC, Servicing Auditor and COR

Error Rate and Adjustment Summary Report (SOW – Section V.I.)

15 calendar days after the Final Reports for all MCOs have been submitted to CMS COR

HHSM-500-2015-RFP-0113 Medical Claims Review for Managed Care Organizations

Self-Assessment/ Lessons Learned Report (SOW – Section V.J.)

15 calendar days after the end of the contract year COR

Round Table Discussion and Materials (SOW – Section V.K.)

As coordinated by CMS, towards the end of the Period of Performance. Any materials to be presented are due at least 5 calendar days prior to the round-table discussion.

COR, in-person presentation

HHSM-500-2015-RFP-0113 Medical Claims Review for Managed Care Organizations

SECTION G – CONTRACT ADMINISTRATION DATA

G.1 Accounting and Appropriation Data

Designated on each task order

G.2 Payments – Invoices - Firm Fixed Price Contracts (AUG 2013)

a. GENERAL: The Contractor may submit to the Government an invoice for payment in accordance with the instructions below.

b. METHOD OF PAYMENT: CMS shall only make an electronic payment of invoices in accordance with FAR 52.232-33, Payments by Electronic Funds Transfer

– System for Award Management. In order to receive payments, the contractor shall register in the System for Award Management (SAM) database, in accordance with FAR 52.204-7, System for Award Management. Failure to register in SAM may prohibit CMS from making payments to your organization.

ADDRESS CHANGES: The contractor shall notify CMS’ Division of Accounting Operations of all EFT and address changes in SAM via the following email address:

CCRChanges@cms.hhs.gov.

c. CONTENT OF INVOICE - Invoices shall include, at a minimum:

• Contractor’s name and address;

• Contractor’s Tax Identification Number (TIN);

• Contractor’s DUNS Number;

• Invoice date;

• Invoice Number to include the designation of the Contract Payment

Category Type as follows:

o Contract Payment Category Type I, II, IV (TBD upon award)

• The CO/CS will:

o Upon Award, insert the correct Contract Payment Category Type in the award document and Remove the others.

• If Type IV is to be used, Insert the following:

“Contract Payment Category Type IV- All Large Businesses with Small Business Subcontractors. When Contract Payment Type IV expires on July 10, 2014, the Contract Payment Type automatically changes to Type II, All Other Contracts (No $ Limit) on July 11, 2014.”

• Remove (TBD upon award)

• Remove the chart below.

• If the contract type is known at the time the solicitation is generated, i.e., small business set-aside, etc., delete the other options and insert the payment type and time frame for payment plus not to exceed 30 days.> mailto:CCRChanges@cms.hhs.gov

HHSM-500-2015-RFP-0113 Medical Claims Review for Managed Care Organizations

• Contract and Order Number, as applicable;

• Contract line item number and/or Subcontract line item number;

• Description, quantity, unit of measure, unit price and extended price of the items actually delivered or services rendered;

• Shipping and payment terms;

• Terms of any discount for prompt payment offered;

• Other substantiating documentation or information as required by the contract;

• Name, title, phone number and complete mailing address of responsible official to whom payment is to be sent;

• Name, title, phone number of person to notified in the event of a defective invoice; and,

• Period of performance or delivery date of goods or services provided.

d. MAILINGS: Invoices shall be submitted as follows:

• ELECTRONIC MAIL: The contractor shall submit an electronic copy of the invoice to both of the following individuals:

• Contract Specialist – Eisha.Banks@cms.hhs.gov

• COR – to be provided at award

INVOICE/VOUCHER REVIEW/APPROVAL PROCESSING TIME FRAMES

Contract Payment Category Types ($ = Total Contract Value) Days = Calendar Days

TYPE I TYPE II TYPE III TYPE IV

Type IA Type IB Type IIIA Type IIIB

TEAM

MEMBER

All Small Businesses (No

$ Limit) All QIOs

(No $ Limit)

All Other Contracts (No

$ Limit)

Simplified Acquisitions

$3K to $150K (Small

Businesses)

Simplified Acquisitions

$3K to $6.5M (Large

Businesses)

All Large Business Prime Contracts with Small Business Subcontractors (from July 11, 2012 through July 10, 2014)

OFM/DAO 7 Days 7 Days 14 Days 7 Days 22 Days 12 Days

COR 4 Days 0 Days 8 Days 8 Days 8 Days 8 Days

CS/CO 4 Days 8 Days 8 Days N/A N/A 8 Days

Total Processing

Time

15 Days Not-to-Exceed

30 Days

15 Days Not-to-Exceed

30 Days 30 Days

15 Days Not-to-Exceed

30 Days 30 Days

28 Days Not-to-Exceed

30 Days mailto:Eisha.Banks@cms.hhs.gov mailto:xxxx.xxxxx@CMS.HHS.Gov

HHSM-500-2015-RFP-0113 Medical Claims Review for Managed Care Organizations

• REGULAR MAIL: An original and one (1) hard copy shall be submitted to the address below:

Department of Health & Human Services Centers for Medicare & Medicaid Services OFM/Division of Accounting Operations P.O. Box 7520 Baltimore, MD 21207-0520

• OVERNIGHT MAIL: If the contractor chooses to use an overnight mail carrier, the original and one (1) hard copy of the invoice shall be submitted to the address below:

Department of Health & Human Services

OFM/Division of Accounting Operations 7500 Security Boulevard/Mailstop: C3-11-03 Baltimore, MD 21244-1850

e. PAYMENTS: The Government shall make payment of all invoices in accordance with

• FAR 52.232-1 Payments, and upon acceptance by the Contracting Officer’s

Representative (COR) in accordance with the applicable FAR Inspection and Acceptance clause and the Contracting Officer’s approval, as appropriate.

Reimbursement for invoices submitted under this contract shall be made not later than thirty (30) calendar days after receipt of an acceptable invoice from the Contractor in the copies requested at the paying office designated above. Any discrepancies determined as a result of the audit could delay the processing of the invoice and may result in the invoice being returned to the Contractor for corrections.

f. INTEREST ON OVERDUE PAYMENT

The Prompt Payment Act, Public Law 97-177 (96 Stat.85.31 U.S.C. 1801) is applicable to payments under this contract and requires the payment of interest on payments made more than 30 calendar days after receipt of an invoice by the Division of Accounting Operations.

Determinations of interest due will be made in accordance with the provisions of the Prompt Payment Act and Office of Management and Budget Circular A-125.

G.3 Contracting Officer’s Representative (COR)

CMS reserves the right to restructure how Contracting Officer’s Representatives (COR’s) are appointed to the contract to meet the needs of CMS.

a. Contracting Officer’s Representative (COR):

HHSM-500-2015-RFP-0113 Medical Claims Review for Managed Care Organizations

The Contracting Officer’s Representative (COR) is authorized to monitor the Contractor performance as set forth in the provisions of the contract. ___TBD__ is delegated authority as the Contracting Officer’s Representative. The Contracting Officer’s Representative’s Technical Direction responsibilities shall include continuous overall monitoring of the Contractor’s compliance with all substantive project objectives. Specific duties and responsibilities are identified in G.4, Technical Direction.

b. In the event that a technical direction dispute cannot be settled between the

COR and the Contractor, the matter will be elevated to the Contracting Officer for resolution. The Contracting Officer will be responsible for settling the dispute. Please also see FAR 52.243-7, Notification of Changes.

G.4 Technical Direction

a. Performance of the work under this contract shall be subject to the technical direction of the COR. The term "technical direction" is defined to include, without limitation, the following:

- Directions to the Contractor which redirect the contract effort, shift work emphasis between work areas or tasks, require pursuit of certain lines of inquiry, fill in details or otherwise serve to accomplish the contractual statement of work.

- Provision of information to the Contractor which assists in the interpretation of drawings, specifications, or technical portions of the work description.

- Review and, where required by the contract, approval of technical reports, drawings, specifications, and technical information to be delivered by the Contractor to the Government under the contract.

b. Technical direction must be within the general Statement of Work stated in the contract. The COR does not have the authority to and may not issue any technical directions which:

(1) Constitutes an assignment of additional work outside the general

Statement of Work of the contract.

(2) Constitutes a change as defined in the FAR contract clause entitled:

52.243-1 CHANGES – FIXED PRICE

(3) In any manner cause an increase or decrease in the total estimated contract cost, fixed-fee, or the time required for contract performance.

(4) Change any of the expressed terms, conditions, or specifications of the contract.

HHSM-500-2015-RFP-0113 Medical Claims Review for Managed Care Organizations

c. All technical direction shall be issued in writing by the COR or shall be confirmed by him/her in writing within 5 working days after issuance.

d. The Contractor shall proceed promptly with the performance of technical direction duly issued by the COTR in the manner prescribed by this article and within his/her authority under the provisions of this article.

e. If, in the opinion of the Contractor, any instruction or direction issued by the COR is within one of the categories as defined in b(l) through b(4) above, the Contractor shall not proceed but shall notify the Contracting Officer in accordance with FAR 52.243- 7, Notification of Changes.

G.5 Contracting Officer Responsibility

In accordance with FAR 52.202-1 Definitions (NOV 2013), the term Contracting Officer means a person with the authority to enter into, administer, and/or terminate contracts and make related determinations and findings. The term includes certain authorized representatives of the Contracting Officer acting within the limits of their authority delegated by the Contracting Officer.

Notwithstanding any of the other provisions of this Contract, the Contracting Officer shall be the ONLY individual authorized to:

a. enter into and commit/bind the Government by contract for supplies or services;

b. accept nonconforming work or waive any requirement of this Contract;

c. authorize reimbursement to the Contractor for any costs incurred during the performance of the Contract, and

d. modify any term or condition of this Contract, i.e., make any changes in the

Statement of Work; modify/extend the period of performance; change the delivery schedule.

G.6 Correspondence Procedures

To promote timely and effective administration, correspondence (except for invoices), submitted under this contact shall be subject to the following procedures:

a. Technical Correspondence - Technical correspondence (as used herein, this term excludes technical correspondence which proposes or otherwise involves waivers, deviations or modifications to the requirements, terms or conditions of this contract) shall be addressed to the COR with an informational copy of the basic correspondence to the Contracting Officer.

HHSM-500-2015-RFP-0113 Medical Claims Review for Managed Care Organizations

b. Other Correspondence - All other correspondence shall be addressed to the Contracting Officer, in duplicate, with an informational copy of the basic correspondence to the COR.

c. Subject Lines - All correspondence shall contain a subject line, commencing with the contract number as illustrated below:

EXAMPLE: Contract No.

Request for Subcontract Consent

G.7 Service of Consultants/ Subcontractors

a. For the purposes of this contract, consultants are considered subcontractors.

b. The Contractor shall follow the procedures established in the following Federal Acquisition Regulation (FAR) clauses when requesting Contracting Officer consent to subcontract for Consultants and/or other subcontracts:

Federal Acquisition Regulation (FAR) Clauses:

52.244-2 Subcontracts (OCT 2010) 52.244-5 Competition in Subcontracting (DEC 1996) 52.244-6 Subcontracts for Commercial Items (MAR 2015)

G.8 Subcontract Consent

a. To facilitate the review of a proposed subcontract by the Contracting Officer’s Representative and the Contracting Officer, the Contractor shall submit the information required by the FAR Clause 52.244-2 (OCT 2010) entitled, "Subcontracts" to the Contracting Officer. The Contracting Officer shall review the request for subcontract approval and the CORs recommendation and advise the Contractor of his/her decision to consent to or dissent from the proposed subcontract, in writing.

b. In the event that proposed subcontracts are intended to be cost reimbursement it is requested that proof of an adequate accounting system be provided to the CO as part of the contractor’s request for consent.

c. Consent is hereby given to issue the following subcontract(s):

TBD

G.9 Dissemination, Publication and Distribution of Information

a. Data and information either provided to the Contractor, or to any subcontractor or generated by activities under this contract or derived from research or studies supported by this contract, shall be used only for the purposes of the contract. It shall not be duplicated, used or disclosed for any purpose other than the fulfillment of the

HHSM-500-2015-RFP-0113 Medical Claims Review for Managed Care Organizations requirements set forth in this contract. This restriction does not limit the contractor's right to use data or information obtained from a non-restrictive source. Any questions concerning "privileged information" shall be referred to the Contracting Officer.

b. Some data or information may require special consideration with regard to the timing of its disclosure so that preliminary findings which could create erroneous conclusions are not disclosed. Also, some data or information, which relate to policy matters under consideration by the Government, may also require special consideration with regard to the timing of its disclosure so that the open and vigorous debate, within the government, of possible policy options is not damaged.

c. Any questions about use or release of the data or information or handling of material under this contract shall be referred to the Contracting Officer who must render a written determination. The Contracting Officer's determinations will reflect the results of internal coordination with appropriate program and legal officials.

d. Written advance notice of at least forty-five (45) days shall be provided to the

Contracting Officer of the Contractor's desire to release findings of studies or research or data or information described above. If the Contractor disagrees with the Contracting Officer's determination, and if this disagreement cannot be settled by the Contractor and the Contracting Officer in a mutually satisfactory manner, then the issue will be settled pursuant to the "Disputes" clause.

e. Any presentation of any report, statistical or analytical material based on information obtained from this contract shall be subject to review by the COR before dissemination, publication, or distribution. Presentation includes, but is not limited to, papers, articles, professional publications, speeches, testimony or interviews with public print or broadcast media. This does not apply to information that made available under the Federal Freedom of Information Act.

f. The COR review shall cover accuracy, content, manner of presentation of the information, and also the protection of the privacy of individuals. If the review finds that the Privacy Act is or may be violated, the release/use of the presentation shall be denied until the offending material is removed or until the Contracting Officer makes a formal determination, in writing, that the privacy of individuals is not being violated.

g. If the review shows that the accuracy, content, or manner of presentation is not correct or is inappropriate in the light of the purpose of the project, the COR shall immediately inform the Contractor, in writing, of the nature of the problem. If the Contractor disagrees, the COR may insist that the presentation contain, in a manner of equal importance, materials which show the government's problem with the presentation.

h. The Contractor agrees to acknowledge support by CMS whenever reports of project funding levels, in whole or in part, by this contract are published in any medium. The Contractor shall include in any publication resulting from work under this contract, an

HHSM-500-2015-RFP-0113 Medical Claims Review for Managed Care Organizations acknowledgement substantially, as follows:

"The analyses upon which this publication is based were performed under Contract Number [ ], entitled, "[ ]," sponsored by the Centers for Medicare and Medicaid Services, Department of Health and Human Services."

Any deviation from the above legend shall be approved, in writing, by the Contracting Officer.

G.10 Data to be Delivered

a. Any working papers, interim reports, data given by the Government or first produced by the Contractor under the contract or collected or otherwise obtained by the Contractor under the contract, or results obtained or developed by the Contractor (subcontractor or consultants) pursuant to the fulfillment of this contract are to be delivered, documented, and formatted as directed by the Contracting Officer.

b. In addition, information and/or data, which are held by the Contractor related to the operation of their business and/or institution and which are obtained without the use of Federal funds, shall be considered “PROPRIETARY DATA” and are not subject data to be delivered under this contract.

G.11 Contractor Past Performance Evaluation(s) (OCT 2014)

a. General:

In accordance with Federal Acquisition Regulation (FAR) 42.1305 Contract Clauses, and FAR 42.15, Contractor Performance Information, past performance evaluations shall be prepared at least annually and at the time the work under a contract or order is completed. Additional interim performance evaluations may be prepared at Contracting Officer discretion, as necessary.

CMS will utilize the Contractor Performance Assessment Reporting System (CPARS), the Government wide evaluation reporting tool for all past performance reports on contracts and orders, as appropriate. CPARS is a secure Internet website located at https://www.cpars.gov.

b. CPARS Process:

1. CPARS Training: Contractors may obtain CPARS training material and register for on-line training https://www.cpars.gov.

2. Post-Award Contract Registration: CMS is responsible for registering the contract in CPARS within 30 calendar days of contract award. The Contractor shall:

i. Designate at least one (1) point of contact that will be responsible for https://www.cpars.gov/ https://www.cpars.gov/

HHSM-500-2015-RFP-0113 Medical Claims Review for Managed Care Organizations serving as the Contractor’s Representative (CR). Additional CRs may also be identified; and,

ii. Provide the CMS Contract Specialist with the name(s) and email address(es) of the CPARS point(s) of contact.

Once CMS registers the contract in CPARS, the CR(s) will receive an automated CPARS email message that contains User IDs and instructions for creating a password for future past performance evaluation processing.

3. Interim, Annual and Final Past Performance Evaluation Reports:

a. Issuing the Evaluation: Once the CMS Assessing Official (AO) issues an evaluation to the Contractor in CPARS, the CR(s) will receive an email instructing them to login to CPARS to review the evaluation.

b. Contractor Comments: The CR has the option to provide comments on the evaluation, indicate if they concur or do not concur with the evaluation, sign, and then return the evaluation to the AO. The CR has a total of 60 days following the AO’s evaluation signature date to submit comments. If the CR submits comments within the first 14 days following the AO’s signature date and the AO closes the evaluation, the evaluation will become available in Past Performance Information Retrieval System - Report Card (PPIRS-RC) within 1 day.

On day 15 following the AO’s evaluation signature date, the evaluation will become available in PPIRS-RC with or without CR comments and whether or not it has been closed by the AO. If no CR comments have been sent and the evaluation has not been closed, it will be marked as “Pending” in

PPIRS-RC.

If the CR sends comments at any time prior to 61 days following the AO’s evaluation signature date, those comments will be reflected in PPIRS-RC within 1 day. On day 61 following the AO’s evaluation signature date, the CR will be “locked out” of the evaluation and may no longer send comments.

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SECTION H – SPECIAL CONTRACT REQUIREMENTS

H.1 Organizational Conflict of Interest

a. General: It is essential that the Contractor and the services provided to Medicare beneficiaries and other Center’s for Medicare & Medicaid Services (CMS) constituents under this contract be free, to the greatest extent possible, of all conflicts of interest. Except as provided below in paragraph c.3 (Exception), the Contracting Officer shall not enter into a contract with an Offeror or maintain a contract with a Contractor that the Contracting Officer determines has, or has the potential for, an unresolved conflict of interest.

b. Disclosure: Contractors must disclose all actual and/or potential conflicts of interest to the Contracting Officer at the time of its offer and during the term of the contract in accordance with paragraph c. below. The Contractor shall have programs in place to identify, evaluate and mitigate all actual and/or potential conflicts of interest that preclude, or would appear to preclude, the Contractor from rendering impartial assistance or advice on work performed for this contract, or the Contractor’s objectivity in performing the contract work is or might be otherwise impaired, or the Contractor has or obtains an unfair competitive advantage. The Contractor’s Organizational Conflict of Interest Certificate that includes the Contractor’s plan to mitigate all actual and/or potential conflicts of interest identified at time of submission and during the term of the contract and certification that all work to be performed under this contract is free of unresolved conflicts of interest will be incorporated into the contract after award.

c. Conflict of interest identification:

1. Definitions: As used in this subpart, the following definitions apply:

(a) Financial relationship means—

(1) A direct or indirect ownership or investment interest (including an option or nonvested interest) in any entity that exists through equity, debt, or other means and includes any indirect ownership or investment interest no matter how many levels removed from a direct interest; or

(2) A compensation arrangement with an entity.

(b) Organizational Conflict of interest— (see FAR 2.101)

(c) Affiliate – (see FAR 2.101)

2. Identification of conflict:

The Contracting Officer determines that an Offeror or Contractor has an actual conflict of interest, or the potential for the conflict exists, if the Offeror is an entity and/or has a present, or establishes a future direct or indirect financial relationship with an entity that is engaged in the following:

HHSM-500-2015-RFP-0113 Medical Claims Review for Managed Care Organizations

The Medical Review Contractor (MRC) and Cost Audit Contractor (CAC) should not be the same as the entity that certifies or prepares the cost report for the particular cost plan under review/ audit. The MRC and CAC should not be the same contractor.

3. Exception. The Contracting Officer may contract with an Offeror or Contractor that has an unresolved conflict of interest if the Contracting Officer finds that it is in the best interest of the United States to award the contract notwithstanding a conflict of interest. In these circumstances, the FAR 9.503 waiver requirements apply.

4. Offeror's or Contractor's responsibility with regard to subcontractors. An Offeror or Contractor is responsible for determining whether a conflict of interest exists in any of its proposed or actual subcontractors at any tier and is responsible for ensuring that the subcontractors have mitigated any conflict of interest or potential conflict of interest. The Contracting Officer shall be notified of such identifications as part of the conflict of interest disclosure requirements stated in paragraph b of this clause.

A Contractor shall maintain documentation necessary to support its determination that its subcontractors have mitigated any conflict or potential conflict. A Contractor may require its subcontractors to follow the procedures for identifying, evaluating and disclosing conflicts of interest and potential conflicts of interest as contained herein.

d. Conflict of interest evaluation:

1. Disclosure. Offerors that wish to be eligible for the award of the MCO Medical Claims Review contract under this subpart must submit, at times specified in paragraph d.2. of this section, an Organizational Conflicts of Interest Certificate.

The Certificate must contain the information specified in paragraphs d.1 (a) through (e) of this section as follows:

(a) A description of all business or contractual relationships or activities that the

Contractor has determined could be viewed as an actual or potential conflict of interest.

(b) A description of the methods the Offeror or Contractor will apply to mitigate any situations listed in the Certificate that could be identified as an actual or potential conflict of interest.

(c) A description of the Offeror's or Contractor's program to monitor its compliance and the compliance of its proposed and actual subcontractors with the conflict of interest requirements as identified in the relevant solicitation.

(d) An affirmation, using language provided below, signed and dated by an official authorized to bind the Contractor:

HHSM-500-2015-RFP-0113 Medical Claims Review for Managed Care Organizations

I, (Name and Title), certify that to the best of my knowledge and belief: 1) I am an official authorized to bind the entity; 2) the information contained in the Organizational Conflict of Interest Certificate is true and accurate as of (Date);

and 3) I understand that the Contracting Officer may consider any deception or omission in this Certificate to be grounds for non-consideration for contract award, modification or nonrenewal or termination of the current contract, and/or other contract or legal action.

An Offeror shall submit an affirmation certifying the information to be true and accurate as of the date the proposal is submitted. Upon award, the Contractor shall submit an updated affirmation, if necessary, certifying the information to be accurate as of the date of contract award.

(e) Corporate and organizational structure.

(f) Financial interests in other entities, including the following:

(1.) Percentage of ownership in any other entity.

(2.) Income generated from other sources.

(3.) A list of current or known future contracts or arrangements, regardless of size, with any—

• Managed Care Organization

• Cost Audit Contractor

(4.) In the case of contracts or arrangements identified in accordance with paragraph d.1(f) (3) of this section, the dollar amount of the contracts or arrangements, the type of work performed, and the period of performance.

2. When disclosure is made. The Organizational Conflict of Interest Certificate is submitted—

(a) With the Offeror's proposal;

(b) When the Contracting Officer requests a revision in the Certificate;

(c) Within 45 days of any change in the information submitted in accordance with paragraph d.1 of this section. The Contractor must notify the Contracting Officer immediately upon identification of an actual and/or potential Organizational Conflict of Interest.

3. Evaluation. The Contracting Officer evaluates actual conflicts of interest and potential conflicts, using the information provided in the Conflicts of Interest Certificate, and information from other sources in order to promote the effective and efficient administration of the Medicare program.

For each conflict identified, the Contracting Officer will evaluate the plan proposed to mitigate the conflict to determine if the mitigation plan will allow the Contractor to render impartial assistance or advice to the Government; or the Contractor’s

HHSM-500-2015-RFP-0113 Medical Claims Review for Managed Care Organizations objectivity in performing the contract work is not or will not be otherwise impaired;

or the Contractor will not or has not obtained an unfair competitive advantage.

4. Protection of proprietary information disclosed.

CMS protects disclosed proprietary information as allowed under the Freedom of Information Act (5 U.S.C. 552).

e. Conflict of Interest Resolution: Resolution of a conflict of interest is a determination that:

(1) The conflict has been mitigated;

(2) The conflict precludes award of a contract to the Offeror;

(3) The conflict requires that the Contracting Officer modify an existing contract;

(4) The conflict requires that the Contracting Officer terminate an existing contract; or

(5) It is in the best interest of the Government to contract with the Offeror or Contractor even though the conflict exists. In these circumstances, the FAR 9.503 waiver requirements apply.

H.2 HIPAA Business Associate Clause (OCT 2014)

All Protected Health Information (PHI), as defined in 45 C.F.R. §160.103, that is relevant to this Contract, shall be administered in accordance with the Health Insurance Portability and Accountability Act of 1996 ("HIPAA," 42 U.S.C. § 1320d), as amended, as well as the corresponding implementing regulations and this HIPAA Business Associate Clause.

a. Definitions:

All terms used herein and not otherwise defined, shall have the same meaning as in HIPAA, as amended, and the corresponding implementing regulations. Non-HIPAA related provisions governing the Contractor's duties and obligations, such as those under the Privacy Act and any applicable data use agreements, are generally covered elsewhere in the Contract.

The following definitions apply to this Contract Clause:

"Business Associate'' shall mean the Contractor (and/or the Contractor’s subcontractors or agents) if/when it uses individually identifiable health information on behalf of CMS, i.e. PHI, to carry out CMS’ HIPAA-covered functions.

"Covered Entity" shall mean the portions of CMS that are subject to the HIPAA Privacy Rule.

"Secretary" shall mean the Secretary of the Department of Health & Human Services or the Secretary's designee.

b. Obligations and Activities of Business Associate:

HHS…