HHSM-500-2015-RFP-0113_Medical_Claims_Review.doc

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 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

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

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 0001- Claim Review

Base Period

CLIN 0002 – Travel

Base Period

CLIN 1002 – Travel

Option Year 1

CLIN 2001- Claim Review

Option Year 2

CLIN 2002 – Travel

Option Year 2

CLIN 3001- Claim Review

Option Year 3

CLIN 3002 – Travel

Option Year 3

CLIN 4001- Claim Review

Option Year 4

CLIN 4002 – Travel

Option Year 4

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:

Year 2012 - 2013

Year 2013

Year 2012 - 2014

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

Example:

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

B.3 Payment Schedule Sub

CLINs

[END OF SECTION]

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.

[END OF SECTION]

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.

[END OF SECTION]

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/

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.

[END OF SECTION]

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

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.

Required Claims Database

Fields (SOW – Section IV.G.b.)

Planning Meeting - With each

Cost Audit Contractor (CAC)

(SOW – Section IV.G.a.)

CAC

Planning Meeting Minutes (SOW

– Section IV.G.a.)

Kick-off Meeting Agenda (SOW

– Section IV.A.d.)

Kick-off Meeting with CMS

(SOW – Section IV.A.d.)

Auditors

Kick-off Meeting Minutes (SOW

– Section IV.A.d.)

Security and Tracking Plan –

Draft (SOW – Section IV.A.f.)

Project Management Plan

(PMP) – Draft (SOW – Section

IV.A.e.)

PMP and Security and Tracking

Plan – Final (SOW – Section

IV.A.e.)

Memo of Understanding

Template (SOW – Section IV.C.a)

Auditors

Auditors

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

20 calendar days following the close of the reported month COR and Servicing Auditors

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

submission window is complete (60 calendar days after preliminary Exit Conference) COR, Servicing

Auditor, CAC

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

draft report COR, Servicing

Auditor and CAC

Formal Reply to Plan

Disagreements to Findings

(SOW – Section IV.G.b.)

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

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

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:

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

· The CO/CS will:

· 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.>

INVOICE/VOUCHER REVIEW/APPROVAL PROCESSING TIME FRAMES

Contract Payment Category Types ($ = Total Contract Value)

Days = Calendar Days

(No $ Limit)

(Small Businesses)

July 10, 2014)

Not-to-Exceed 30 Days 15 Days

Not-to-Exceed 30 Days

Not-to-Exceed 30 Days

Not-to-Exceed

30 Days

· 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

· 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

Centers for Medicare & Medicaid 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):

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.

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.

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 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 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 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.

[END OF SECTION]

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:

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:

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 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:

Except as otherwise provided in this Contract, Business Associate, as defined above, shall only use or disclose PHI on behalf of, or to provide services to, Covered Entity in accordance with this Contract and the HIPAA Privacy and Security Rules.

Business Associate shall document in writing the policies and procedures that will be used to meet HIPAA requirements. The policies and procedures shall include the following, at a minimum:

1. Business Associate shall not:

a. Use or disclose PHI that is created, received, maintained or transmitted by Business Associate from, or on behalf of, Covered Entity other than as permitted or required by this Contract or as required by law;

b. Sell PHI; or,

c. Threaten, intimidate, coerce, harass, discriminate against, or take any other retaliatory action against any individual for:

i. Filing a complaint under 45 CFR § 160.306;

ii. Testifying, assisting or participating in an investigation, compliance review, proceeding or hearing under 45 CFR Part 160; or

iii. Opposing any act or practice that is unlawful under HIPAA, provided there is a good faith belief that the practice is unlawful, the manner of opposition is reasonable, and the opposition does not involve the disclosure of PHI in violation of subpart E of Part 164.

2. Business Associate shall:

a. Have a security official who will be responsible for development and implementation of its security policies and procedures, including workforce security measures, to ensure proper security awareness and training (including security incident response and reporting), and security incident procedures, in accordance with this Contract, including this HIPAA Business Associate Clause and the Contract’s clause entitled “CMS Information Security.”

b. Use administrative, physical and technical safeguards to prevent use or disclosure of PHI created, received, maintained or transmitted by Business Associate from, or on behalf of Covered Entity only as provided for by this Contract. In doing so, it shall implement policies and procedures to address the following and, where applicable, ensure that such policies and procedures are also in conformance with this Contract’s clause entitled “CMS Information Security:”

i. Prevent, detect, contain and correct security violations through the use of:

1. Risk analyses (including periodic technical and nontechnical evaluations);

2. Appropriate risk management strategies, including system activity review;

3. Information access procedures for approving individual’s access rights to PHI (including the implementation of workforce security measures to ensure continued appropriate role-based access to PHI), and technical policies and procedures to ensure compliance with grants of access (including unique user identification and tracking of users) and;

4. The imposition of sanctions for violations.

ii.

Limit physical access to its electronic information systems and the facility or facilities in which they are housed.

iii. Implement policies, procedures and physical security measures that will limit access to PHI through workstations and other devices, including access through mobile devices. Implement media controls covering the movement of devices containing PHI within or outside of the Business Associate’s facility as well as the disposal and reuse of media containing PHI.

iv. Implement appropriate administrative, physical and technical safeguards that reasonably and appropriately protect the confidentiality, integrity and availability (including the use of contingency plans) of any electronic protected health information ("EPHI") it creates, receives, maintains or transmits from, or on behalf of the Covered Entity to prevent impermissible use, disclosure, maintenance or transmission of such EPHI. In the establishment of such safeguards, Business Associate shall consider its size, complexity and capabilities, as well as its technical infrastructure, and its hardware and software security capabilities.

c. Assess, and implement, where appropriate, any addressable implementation specifications associated with applicable PHI security standards.

d. Mitigate, to the extent practicable, any harmful effect that is known to Business Associate of a use or disclosure of PHI by Business Associate in violation of the requirements of this Contract.

e. Comply with the following Incident Reporting:

Report to Covered Entity any security incident/breach involving unsecured PHI, of which it becomes aware, including those of its agents and subcontractors. The Business Associate shall report any violation of the terms of this contract involving PHI and any security incidents/breaches involving unsecured PHI to CMS within one (1) hour of discovery in accordance with the CMS Risk Management Handbook (RMH), specifically “RMH Vol II Procedure 7-2 Incident Handling Procedure” and “RMH Vol III Standard 7-1 Incident Handling.” These procedures can be found at http://www.cms.gov/Research-Statistics-Data-and-Systems/CMS-Information-Technology/InformationSecurity/Information-Security-Library.html In addition, the Business Associate will also notify the CMS Contracting Officer and the Contracting Officer’s Representative (COR) by email within one (1) hour of identifying such violation or incident.

Upon Covered Entity's knowledge of any material security incident/breach by Business Associate, Covered Entity will provide an opportunity for Business Associate to cure the breach or end the violation consistent with the termination clause of this Contract. See also paragraph D. Term of Clause below.

f. Ensure that any agent or subcontractor agrees through a written contract, or other legally enforceable arrangement, to the same restrictions and conditions that apply through this HIPAA Contract Clause, when creating, receiving, maintaining or transmitting PHI from, or on behalf of, Covered Entity.

g. Upon Covered Entity’s request:

i. Provide the Covered Entity or its designee with access to the PHI…