E.4 Answers to Draft Solicitation Questions.xlsx

CPI Sheet

What data sources and data should offerors assume will be available through One PI/IDR at the award of the first Task Order? For example:

What Medicare data sources?

What Medicaid data sources and from which states?

Claims data? Provider Data?

Age of claims?

Adjudication status?

In addition, what is the anticipated timeline for any additional data sources becoming available? National Claims History (Medicare Part A/B/DME):

• Post Payment

• Data Range: CY 2006-Present

• Frequency: Weekly

Shared Systems (FISS, VMS, MCS):

• All Phases and Locations

• Data Range: FY 2012-Present

• Frequency: Daily

Medicare Part C (Encounter):

• Data Range: CY 2012-Present

• Frequency: Biweekly

Medicare Part D (PDE, NDC):

• Data Range: CY 2006-Present

• Frequency: Daily

Medicare Beneficiary Eligibility (CME):

• Medicare Beneficiary Database (MBD)

• Eligibility Database (EDB)

• Medicare Advantage & Part-D Inquiry System (MARx)

• SSA Death Master File (DMF)

Medicare Provider Enrollment:

• Provider Enrollment, Chain, and Ownership System (PECOS)

• National Plan and Provider Enumeration System (NPPES)

• National Provider Identifier Crosswalk System (NPICS)

• Provider of Services (POS)

• Part B Provider Extract (ProvBX)

• National Council for Prescription Drug Programs (NCPDP)

Medicare Program Integrity:

Relative Value Units Physician Fee Schedule Compromised Number Checklist Medicare Exclusion Database Fraud Investigation Database Beneficiary Integrity Unit (BIU) Medical Review/Utilization Review (MRUR) Technical A-UPIC Draft USOW 26 5.2+ DASG/SMD The following questions refer to all instances of UCM and OnePI/IDR throughout the draft USOW, beginning with page 26, Section 5.2 Data Analysis and Matching Requirements.

Will CMS provide detailed specifications or additional documentation for the functionality contractors should assume will be present within the UCM (or alternative environments) on Day 1, and projected for the contract term? Such information would assist offerors in knowing what additional tools or capabilities might be necessary to support their internal operations. CMS will provide documentation regarding UCM with the RFP.

Technical A-UPIC Draft USOW 26 5.2.3 DASG/SMD "The UPIC shall collaborate with the states in their jurisdiction to develop a comprehensive strategy for data analysis involving Medicaid data."

Does this mean the UPIC will only participate in Medicare Appeals if requested to support the determination?

As edits are traditionally implemented in Shared Claims Processing System, can CMS please expand upon the planned functionality to develop edits in FPS?

Would CMS consider including the "sentinel" effect in the assessment of program effectiveness?

In the Program Integrity Manual, Ch 15 Sec 15.27.2 I - Regarding Revocations, its states Medicaid is notified of revocations by CMS via the SharePoint Ensemble site. Will the SharePoint Ensemble site continue to operate in the UPIC environment?

Is it planned that when the UCM is integrated with the Medicare shared systems that updates to claim determination will be auto populated in the system based upon claim review decisions?

ii. During the transition period, the UPIC shall participate in training sessions for the Unified Case Management System, as directed by the CMS COR team..."

Recognizing that CMS continues to develop and/or mature solutions such as One PI, IDR and UCM over time, what assumptions, if any, should offerors use with respect to delivering or pricing short term business solutions that may be necessary to supplement or augment these solutions?

For example:

CMS indicates that certain requirements will be addressed through the UCM, or in an alternative environment as directed by CMS. Can CMS clarify that the alternative environment(s) mentioned in the SOW will be provided by CMS and should not be included in any technical or pricing solution by offerors?

If certain data specified by the SOW or required to support contractor operations is not yet available in One PI/IDR, will the contractor be expected to extract, load, and transform that data into their own data warehouse or directly into the IDR for analysis?

Can CMS clarify this requirement?

How should the contractor handle FMAP when the overpayments are extrapolated across multiple periods? To determine the federal share of the overpayments, follow the same logic outlined in the Statistical Sampling worksheet. Complete the following steps:

1. Apply the appropriate FMAP percentage to each overpayment to compute the federal share amount;

2. Combine all federal share overpayment amounts by Strata and input the information in RAT-STATS;

3. Determine the lower bound for the total overpayment and the federal share; and

4. Summarize both calculations (total overpayment and Federal Share) and the results.

Technical B-UPIC Task Order SOW 4 A CMG/DASP

• Costs associated with development of an investigation shall be allocated based on the focus area(s) of the investigation. Please provide clarification on what CMS considers the focus area of the investigation (ie program, clairm type, administrative actions taken, provider specialty)

• Cost per investigation;

• Cost per audit;

• Cost per standalone medical review;

• Cost per administrative action;

Note: the above items shall include a numerical identifier matching UCM and grouped by state.

• Medi-Medi expenditures by state; and

• Medicaid expenditures by state.

Please provide detail on how these costs will be tracked by the UPIC? What cost elements are included in deriving the cost required above?

• Communicate efficiently (e.g., e-mail) within its own departments, other specialty contractors (when implemented), CMS, MACs, law enforcement, etc.;

• Provide systems to compile information for management reports.

• Receive any applicable Medicare and Medicaid financial reports; and

• View the claims attachment images, if applicable."

…"3. Approach to Meeting Quality Assurance Program Requirements

i. Provide an approach and plan for meeting Quality Assurance Program Requirements that adequately address the following:"

1. ISO registration or a plan for obtaining ISO registration within one year of contract award;

2. IT Security Requirement Compliance

3. Acceptance of all USOW and TO SOW requirements

4. All proposed Key Personnel meet all SOW requirements including location requirements."

Please clarify the information CMS would like included in the IT Security Requirements Compliance Attestation.

122 L.5 L.8.D.2

STATEMENT OF WORK

Jurisdiction 1"

Will CMS provide a listing of personnel positions and required clearance levels with the final solicitation?

Additionally, as this timeline can be very lengthy, can CMS clarify if personnel will be able to perform on the contract while the Security Clearance process is being completed?

Finally, will CMS permit employees to perform on the contract, on an interim basis until the CMS security clearance process completes, if the contractor and their subcontractors follow a background investigation process that aligns with CMS and OPM guidance for Program Integrity work? Suggested language: Per the clause, the COR and the Security Emergency Management Group, shall perform a position-sensitivity anaylsis after contract award.

CMS Personnel Security has confirmed that the contractor will be abllowed to work on the contract while the investigation is being conducted.

Other E-UPIC Draft Solicitation 34-44 H.5 CMG/DASG 6. UPIC Jurisdictions The UPIC jurisdictions, previously outlined in Draft SOW may further exacerbate the issues outlined above and limit competition. For example, the current UPIC jurisdictions do not align with the MACs, RACs or other CMS contracting structures. Due to these inconsistencies, UPIC offerors that support these contracts as a prime or subcontractor will be limited in the number of Task Orders in which they can ultimately compete. Furthermore, if CMS ultimately finalizes its decision to have five UPIC jurisdictions with expansive geographies, this has a sizeable impact on competition, especially when considering that viable offerors will likely have other government healthcare program business in these geographies.

In light of the expansive government programs that could create an OCI with UPIC, will CMS take into consideration the number of jurisdictions and alignment with other CMS programs to maximize competition and minimize the possible reach of any or all of these conflicts?