OM AdQIC SOW.pdf

Attachment J-1 – Statement of Work

RFP 75FCMC26R0054 (AKA RFP 260025J)

ADMINISTRATIVE QUALIFIED INDEPENDENT CONTRACTOR (AdQIC)

TASK ORDER

Attachment J-1 - STATEMENT OF WORK

I. SCOPE

The contractor shall provide administrative services in support of the Qualified Independent Contractors (QICs) that perform adjudication services in accordance with §1869 of the Social Security Act, as amended by both the Medicare, Medicaid, and State Children’s Health Insurance Program (SCHIP) Benefits Improvement and Protection Act (BIPA) of 2000 and the Medicare Prescription Drug, Improvement and Modernization Act (MMA) of 2003.

A. Background

The Administrative QIC (AdQIC) Task Order (TO) includes providing appeals training and coordination, long term case file storage, referrals to the Medicare Appeals Council within the Departmental Appeals Board (herein Appeals Council) and notifying Medicare Administrative Contractors (MACs) to effectuate Administrative Law Judges (ALJ) and Appeals Council decisions.

B. Purpose

The purpose of the AdQIC is to provide support to each of the QICs and to ensure that, at a minimum, the following functions are performed:

• Collect, consolidate, store, maintain, and distribute information regarding the receipt, processing and disposition of reconsideration and expedited reconsideration requests;

• Develop, maintain, distribute, and update reconsideration and expedited reconsideration review protocols;

• Maintain, distribute and update the QIC Manual;

• Review reconsideration and expedited reconsideration data for statistical and analytical purposes, including the production of management information reports, to include trend analysis and recommendations for continuous quality and process improvement;

• Coordinate and conduct QIC training on all aspects of the reconsideration process;

• Activities associated with ALJ and Appeals Council hearings, including:

- Maintaining the Electronic Notice of Hearing (eNOH) Portal for coordinating contractor participation in hearing and ensuring seamless communication of participating parties from the site to the ALJ;

- Preparation and transfer of case files to the Office of Medicare Hearings and Appeals (OMHA), Appeals Council, or to Federal District Court;

- Review, analyze, and forward ALJ and Appeals Council effectuation data related to all decisions (i.e., partially favorable, favorable, and/or unfavorable cases that involve changes in liability) to all MACs and,

- Analyze ALJ decisions to determine whether a request for Appeals Council review is appropriate.

• Coordinate various QIC, MAC, and OMHA activities.

C. Technical Considerations:

• The following are the minimum specifications of the PC hardware and software that the

QIC will need to procure for implementation of the MAS:

QIC Desktop Computer Notes Operating System Microsoft Windows 10 or later Processor Pentium 4 Processor 2.8 GHz or equivalent Memory size 8 GB Disk size 200 GB Monitor 17” Color (dual monitors recommended) CD-ROM Drive For Installation of Software Software Microsoft Office 2016 or latest version

Java version 1.8 Adobe Acrobat Reader (recommended) TIFF image reader (recommended)

Web Browser Chrome, Edge, or latest version specified by MAS support

Anti-Virus software Anti-virus software must be kept up to date and full virus scans must be performed weekly.

II. REQUIREMENTS

The QIC umbrella statement of work (USOW) is incorporated into this Task Order (TO) with the same force and effect as if it were provided in full text. Independently and not as an agent of the Government, the AdQIC shall furnish all the necessary services, qualified personnel, materials, equipment, and facilities, not otherwise provided by the Government**, as needed to perform the requirements of the QIC USOW and this task order SOW.

**If the contractor chooses to utilize/maintain utilization of CMS Amazon Web Services (AWS) as a means of hosting application(s), website(s), or as a storage/disaster recovery site the contractor may do so. The CMS AWS is billed to the CMS component directly and cannot be billed to a contractor.

The AdQIC shall perform all the requirements of the USOW EXCEPT FOR THE FOLLOWING

SECTIONS:

I.A.2 Medicare Part C and the Programs of All-Inclusive Care for the Elderly (PACE) Program

I.A.3 Medicare Part D I.A.6 The Medicare Part C Appeals Process I.A.7 The Medicare Part D Appeals Process II.A.2 Document Imaging II.B.6 Award Fee Plan Self-Assessment III. A Reconsideration Adjudication III.A.1 Processing Reconsiderations III.A.2 Acknowledgement Letters III.A.3 Timely Adjudication of Reconsiderations III.A.4 Medicare Appeals System (MAS) Data Entry III.C Record Review III.C.1 Basis for Reconsideration Decision III.D Reopenings III.E Effectuation of Reconsideration Decision III.F Holding Unfavorable and Partially Favorable Reconsideration Decisions III.F.1 Folder Transfer to the ALJ Hearing Offices (except as outlined in Task 9) III.G Expedited Reconsiderations III.G.1 Dismissal of request for Expedited Reconsideration III.G.2 Expedited Reconsideration Decision IV. A Notice of Reconsideration Decision or Notification of Processing Delay IV.B.2 Quarterly AC and QIO Meetings IV.G.3 Panel of Clinical Experts V.A.2 QIC Retrospective Reviews VI Award Fee Plan

The following is a minimum specification of the CMS security policies that must be maintained:

AdQIC Notes

CMS Rules of Behavior Form To be completed by the AdQIC individuals who will be accessing the AdQIC network remotely prior to receiving a CMS User ID.

CMS Interconnection Security Agreement

To be completed by the AdQIC as an Organization 15 days after the date of award.

CMS Data Use Agreement To be completed by the AdQIC as an Organization 30 days after the date of award.

Security Test of the QIC infrastructure

Will occur 60 days after date of award, at CMS discretion, or to align with scheduled Authority to Operate (ATO) and Cybersecurity and Risk Assessment Program (CSRAP) as defined by the System’s Information System Security Officer (ISSO)

CMS Acceptable Risk Safeguards

(ARS)

CMS information technology (IT) security policy to enforce FISMA1 compliance for all IT systems.

CMS Business Partner System Security Manual (BPSSM)

CMS IT security policy for business partners who utilize CMS data and connect with CMS systems.

Note: In accordance with the BPPSM, the AdQIC shall undergo a security audit and obtain an ATO within 6 months of contract award or maintain ATO as applicable.

A. Phases

The period of performance (POP)* is as follows:

Transition-In: July 14, 2026 – September 13, 2026 Base Period-Operational September 14, 2026 – September 13, 2027 Renewal Period I: September 14, 2027 – September 13, 2028 Renewal Period II: September 14, 2028 – September 13, 2029 Renewal Period III: September 14, 2029 – September 13, 2030 Renewal Period IV: September 14, 2030 – July 13, 2031 Transition Out (optional): May 14, 2031 – July13, 2031

*Please Note: CMS reserves the right to modify or adjust applicable dates as necessary;

however, the total period of performance for the task order should not exceed five (5) years.

A.1 Transition Phase (Transition-In- if necessary):

The transition phase shall begin on July 14, 2026 and shall conclude no later than September 13, 2026. The AdQIC shall ensure that the following actions, at a minimum, are accomplished during the transition phase:

• Procuring necessary facilities and hiring/training staff;

• Establishing CMSnet connectivity;

1 Federal Information Security Management Act of 2002 (P. L. 107-347)

• Testing the MAS connectivity;

• Working with/communicating with the outgoing AdQIC to ensure a smooth transition;

• Commenting on the protocols the AdQIC has drafted; and,

• Coordinating and developing Joint Operating Agreements (JOAs) with the MACs, Unified Program Integrity Contractor (UPICs), Recovery Audit Contractors (RACs), the QICs, and Memorandum of Understanding (MOU) with OMHA (see Task 1f).

When the AdQIC has successfully completed all transition phase activities, it shall submit a “Letter of Readiness” to the COR and upload it to CMS ART or other specified CMS Deliverable System of Record attesting to the fact that the AdQIC is ready to proceed to the operational phase. The “Letter of Readiness” shall be completed and sent to the COR on or before the last day of the transition period.

A. 2: Operational Phase (Base Period):

The AdQIC operational phase shall commence on September 14, 2026. During the operational phase, the AdQIC, at a minimum, shall:

B. Specific Tasks to be performed

The following tasks are in addition to those already defined in the USOW.

Initial Meeting/Kickoff Conference

Meeting with CMS: In preparing to implement new requirements, the AdQIC shall arrange an initial meeting/kick-off conference with CMS. This meeting shall be held no later than 7 calendar days after the TO award and shall be held via teleconference or online medium compatible with CMS computer systems. Prior to this meeting, the AdQIC shall provide CMS with information regarding the new mailing address (postal and courier information), email addresses, list serves other pertinent contact information for CMS, OMHA, QICs, and other CMS Stakeholders.

Following the meeting, the AdQIC shall be responsible for providing meeting minutes to the COR related to the initial/kick off conference with CMS. These minutes shall be submitted to the COR within three (3) business days following the meeting.

Meeting with the QICs:

The AdQIC shall also hold this meeting no later than 10 business days after TO award and shall occur via teleconference or online medium compatible with CMS computer systems. A discussion regarding the existing AdQIC/QIC JOA and any necessary changes identified shall occur at this meeting and suggestions regarding changes shall be presented prior to this meeting.

If necessary, additional workgroup meeting shall be scheduled to ensure a smooth transition. If a transition is not applicable and upon review of the SOW, the AdQIC determines new/initial kick off meeting with the QICs is not necessary, the AdQIC can notify the COR via email prior to the 10-business day requirement.

Meeting with the MACs:

The AdQIC shall arrange initial meetings(s) with the A/B MACs, and DME MACs. This/these meetings shall be held no later than 15 business days after TO award and shall be held via teleconference/online medium compatible with CMS computer systems. A discussion regarding the existing AdQIC/MAC JOA and any necessary changes identified shall occur at this meeting and suggestions regarding any potential changes shall be presented prior to the conference call. If necessary, additional workgroup meeting shall be scheduled, as necessary, to ensure a smooth transition. If a transition is not applicable and upon review of the SOW, the AdQIC determines new/initial kick off meeting with the MACs is not necessary, the AdQIC can notify the COR via email within 15 business days.

Meeting Minutes for all Kick off Meetings & Follow up Transition Meetings:

The AdQIC shall be responsible for providing draft meeting minutes and deliverables listing, as applicable, to the COR no later than 3 business days following each meeting. Final meeting minutes and deliverable lists shall be provided to the COR and all related participants within 3 business days of receipt of any comments from the COR.

Task 1: Project Administration

The AdQIC shall provide all services necessary to administer the contract and support services with CMS and Medicare contractors.

Task 1a: Project Plan

As applicable, the AdQIC shall develop a transition management team to ensure communication, cooperation, consultation, and coordination between the MACs, QICs, OMHA, Appeals Council, and other related entities, is maintained in support of the transition. If required to support successful implementation of the activities in this SOW, the team shall have regular meetings and shall monitor the work of any applicable subgroups during the transition. The AdQIC shall continue to ensure effective and efficient communication, cooperation, consultation, and coordination between the AdQIC and the QICs, MACs, OMHA, and the Appeals Council is maintained.

Upon contract award, the AdQIC shall review ongoing operations to determine if a project plan is necessary to support changes incorporated under this SOW. If applicable, the AdQIC shall submit to the COR a project plan for incorporating new requirements under this SOW into ongoing operations within 10 business days after contract award. The AdQIC shall incorporate any comments/edits from the COR within 5 business days of receipt. The final plan shall be submitted no later than 15 business days after the initial meeting/kickoff meeting. These shall be submitted as a Microsoft Project or an equivalent software package with applicable narrative information.

As applicable, project plans shall be modified and updated continuously after these initial submissions to reflect any major changes in the project during the transition period. A major change is defined as something that shifts the work or plan by at least 30 days. When changes are identified, the AdQIC shall submit a draft plan to the COR for review within 10 days of identifying the change.

The COR will provide comments to the AdQIC within 15 days, and the AdQIC shall deliver the final plan within 10 days after receipt of the COR’s comments. If the COR’s comments are not received within 15 days, the plan is assumed to be final.

Task 1b: Joint Operating Agreements (JOAs)

Establishing New JOAs, as applicable:

Upon contract award, the AdQIC shall review the existing JOA templates relative to the AdQIC/QICs, AdQIC/MACs, QICs/MACs, QICs/Recovery Audit Contractors (RACs), QICs/Unified Program Integrity Contractors (UPICs), and QICs/Quality Improvement Organization (QIO) relationships to determine if additional changes are necessary as result of the SOW requirements.

• Establishing New JOAs, as applicable: Should the AdQIC not already have established

JOAs with the QICs/MACs/UPICs/RACs, the AdQIC shall submit a draft written JOAs to the COR and the relevant party to each JOA for comment no later than 15 days after the transition phase begins. For purposes of this section, the relevant party to the JOA is defined as the MAC, UPIC, RAC, and QICs. The AdQIC shall submit final written JOAs to the COR and the relevant party no later than 15 calendar days prior to the start of the operational phase. The AdQIC shall obtain the appropriate signatures from the relevant party on the JOA and submit the final signed JOA to the Contracting Officer (CO) no later than the first day of the fully operational period. The AdQIC shall furnish a copy of the signed JOA to the COR, Contract Specialist (CS), and the relevant party.

Upon contract award, the AdQIC shall also review the existing JOAs between the AdQIC/QICs and the AdQIC/MACs to determine if edits/changes are needed to support the requirement of this contract. If additional edits and changes are required or signed JOAs are not currently in place between the AdQIC/QICs and AdQIC/MACs, the AdQIC shall complete these updates and/or establish new signed JOAs no later than 30 business days after contract award or 10 business days prior to start of operation phase whichever is shorter.

• Updating Existing JOAs, as applicable: If the AdQIC has existing JOAs with the relevant parties noted above, the AdQIC shall update the existing JOAs, as applicable, based upon the requirements in this SOW and obtain concurrence on the revised JOAs no later than 15 days prior to the start of the operational phase. The AdQIC shall obtain the appropriate signatures from the relevant party on the JOA and submit the final signed JOA to the CO no later than the first day of the fully operational period. The AdQIC shall furnish a copy of the signed JOA to the COR, CS, and the relevant party.

Thereafter, the AdQIC shall be responsible for reviewing and updating all JOA templates currently in existence and any future JOAs requested by the COR on an annual basis. The AdQIC shall provide written notice to the COR and respective/related entities regarding suggested changes no later than January 1st, annually. The AdQIC shall provide the related entities at least 15 days to review/provide feedback regarding the suggested changes.

Finalized/revised templates shall be completed no later than 15 days after receipt of comments from the COR and related entities. The AdQIC shall track changes through an appropriate means from the previous document and distribute changes to the relevant parties. If no changes are identified, the AdQIC shall submit a statement to the COR to this effect.

Occasionally, the COR may also ask the AdQIC to develop interim language for related entities to use/incorporate into existing JOAs outside of the annual review process.

The JOAs will not be incorporated into task order contracts, as this document is a mutual agreement between the AdQIC and the relevant party to the JOA. However, the JOAs shall contain, among other things, a dispute resolution process, which details the steps to be followed in the event of a dispute between the QIC and the relevant party to the JOA with regard to the terms and conditions of the JOA.

At a minimum, the AdQIC and the relevant party shall first attempt to resolve the above issue(s).

If they are unable to come to a resolution, the matter shall be raised to the respective CORs. In the event that a dispute between the AdQIC and the relevant party to the JOA cannot be resolved by the COR and related parties within 30 days (excludes budget issues), the AdQIC shall direct the issue in writing to the CMS CO, CS, and the COR for resolution by a JOA Alternative Dispute Resolution (ADR) team. CMS will determine the members of the ADR team on a case by-case basis depending on the issue(s). The ADR team will issue a determination on the matter in writing to both the AdQIC and the relevant party to the JOA.

Reports to CMS of QIC non-compliance will be investigated. If the non-compliance issue is validated, at a minimum, it will be considered an adverse finding in the annual performance evaluation.

Task 1c: Monthly Progress Report

The AdQIC shall submit a monthly progress report to the COR and the CO by the 15th of the month for the previous month’s effort IAW section II.B.1 of the USOW. Upon contract award, the COR will provide additional information regarding reporting needs however, at a minimum, the report shall briefly state the progress made regarding difficulties encountered during the reporting period, as well as any remedial action taken, and a statement of activity anticipated during the subsequent reporting period. The report shall also detail case file, ALJ/Appeals Council decision reviews, effectuation and referral processing actions, volume of case files sent to OMHA, volume of ALJ case files received by the AdQIC, and case file requests from Office of General Council (OGC).

Task 1d: Cost Reports

The AdQIC shall submit a monthly cost report that details all costs incurred for the previous month. The AdQIC shall submit the cost report to the COR by the 20th of each month and to the Contract Specialist (electronic copy) via Invoice Processing Platform (IPP) with the monthly invoice that indicates at a minimum the current monthly costs, cumulative to date costs, and remaining funding IAW section II.B.5 of the USOW.

The report shall track costs by:

• Labor categories

• Hours per labor category

• Labor rates

• Fringe benefits

• Travel costs

• Other direct costs

• Subtotal costs

• Fees/profit

• Total costs

• Unit Costs

• If there are one-time costs or atypical items a brief summary shall be included in Other

Direct Cost Section

Task 1e: Future Enhancement Report (FER)

The AdQIC shall submit recommended changes or improvements to the Medicare appeal process throughout the year IAW section II.B.2 of the USOW. Such recommendations should include, but are not limited to:

• Situations suggesting the need for increased education of providers or suppliers;

• Recommendations for changes to the appeals process to reduce the number of reconsiderations;

• Lessons learned during the year;

• Actionable recommendations for how to address or improve upon lessons learned from previous year for including but not limited to specific contractors, specific CMS components, or specific policies;

• Recommendations to initiate or revise national and local coverage determinations policies;

• A prioritization of proposed improvements;

• A discussion of the rationale for each proposed change;

• Identification of changes to regulations or statutes necessary to authorize such process improvements;

• Identification of the benefits and costs associated with implementing these changes, and

• Provide in proposal any additional areas of focus that should be included as part of FER.

Upon award work with COR to identify other areas for review, reporting, and improvement that may benefit the entire Medicare Program.

These recommendations shall be compiled annually, updated with any actions taken and submitted to the COR no later than August 15th of each year.

Task 1f: CMS/OMHA/AdQIC Memorandum of Understanding (MOU):

The AdQIC shall also be responsible for complying with the requirements as outlined in the attached draft CMS/OMHA/AdQIC MOU (see Attachment J-3). The MOU shall outline the policies and procedures for the AdQIC’s interactions with OMHA. CMS shall work with OMHA and the AdQIC to review the MOU and update it on an annual basis.

While CMS will lead the negotiations of any changes to the MOU, the AdQIC shall be responsible for expeditiously reviewing any suggested changes and providing feedback to CMS.

Additional information regarding this process shall be provided upon contract award. Reports to CMS of QIC non-compliance with the terms of the MOU will be investigated. If the non-compliance issue is validated, at a minimum, it will be considered an adverse finding in the annual performance evaluation.

Task 2: Training

The AdQIC shall plan and deliver training sessions to entities as directed by the COR. At a minimum, the AdQIC training sessions shall include:

• Use of the MAS IAW § IV.B.3 of the USOW;

• Medicare coverage and medical necessity reconsideration analysis IAW § IV.B.3 of the

USOW;

• Medicare policies updates and/or changes; and

• Use of the protocols IAW §§ II.E.1 and IV.B.4 of the USOW.

Additional training topics may be required depending on the needs of CMS and/or as otherwise directed by the COR. The training provided by the AdQIC may require travel to each of the QIC’s and/or other locations.

All deliverables shall be compliant with Section 508 requirements of the Rehabilitation Act.

Virtual Classes- All virtual classes must be delivered using a 508 compliant platform and shall be compliant with Section 508 of the Rehabilitation Act.

Course Materials- All course materials (hard copy or electronic presentations, handouts, aides, and guides) shall be compliant with Section 508 of the Rehabilitation Act and delivered to all participants at least five (5) business days before the start of class. However, the parties understand that this time period may be shortened due to unanticipated circumstances, for example, ad-hoc trainings, trainings to address urgent matters, etc. If requested, an electronic version (i.e., cd or electronic pdf) of the training materials should be made available to CMS.

Task 2a: Initial Training - QIC

The AdQIC shall provide initial training for all new Original Medicare QIC task orders. This initial training, at a minimum, shall include medical necessity, coverage criteria, decision letter writing, QIC protocols developed by the AdQIC, and the MAS.

Task 2b: Follow-up Training - QIC

The AdQIC shall provide refresher training for QICs on an as needed basis and on approval by their COR. Instances that may require refresher training would include: Major MAS releases, Cognos Changes, upgrades and modifications to reporting, significant Medicare policy changes, or the identification of a high rate of error in decision-making at a particular QIC.

Task 2c: Initial Training - MAC

The AdQIC shall provide initial training for all new MAC contracts, as well as all existing MACs at the time that each gains write-access to MAS. This initial training, at a minimum, shall include the use of the MAS for Cognos reporting.

Task 2d: Follow-up Training -MAC

The AdQIC shall provide refresher training for contractors on an as needed basis and on approval by their COR. Instances that may require refresher training would include upgrades and modifications to reporting, and major MAS-Cognos changes.

Task 2e: Educational Updates—Review of CMS Change Requests (CRs)

The AdQIC shall review all pending and final CRs released by CMS. Pending CRs are defined as CRs that are currently in the Point of Contact (POC) review period in the CMS CR system eCHIMP. The AdQIC shall determine if pending and final CRs will impact the Medicare FFS appeals process or are relevant to the appeals process in another way by describing a change in coverage, billing, or payment policy. If the AdQIC determines that a pending CR will have an impact on the QIC program (including but not limited to policy, budget, volume, or procedure), the AdQIC shall coordinate a reply with CMS and/or other QICs, as necessary, to post a comment in eCHIMP before the POC review period expires. The AdQIC shall ensure that the comment is incorporated into the pending and final CR. The AdQIC shall distribute the final CRs it deems appropriate to all the QICs for educational purposes including a summary of the CR and an analysis of impacts to the QIC operations.

Task 2f: Protocols

The CMS has existing review protocols to ensure the efficiency and consistency of the reconsideration adjudication across all QIC jurisdictions. The AdQIC shall review, maintain and update existing protocols, as well as develop new protocols IAW sections II.F.1and IV.B.4 of the USOW. New protocols shall be developed as needed/as identified by AdQIC or QIC community/at the direction of the COR. Existing protocols shall be reviewed on a bi-annual basis ( January 1 and July 1) to determine if additional updates are necessary. If no updates are necessary, the AdQIC shall submit a statement to that effect to the COR. In addition to the existing USOW requirements, the AdQIC shall maintain current and past protocols on their website for reference.

Task 2g: Website

The AdQIC shall develop, host, and maintain a website with both public and private/restricted access to support the QICs in their respective reconsideration adjudication tasks and provide information regarding the QICs and the appeals process to appellants and other stakeholders. The AdQIC shall continue existing website content and functionality and add additional appeals information, as defined below and further directed by CMS, within 30 calendar days of contract award. At a minimum, the publicly available section of the website shall include:

• Links to the other QICs websites;

• Link to OMHA’s website;

• Links to statutory and regulatory provisions governing the QICs;

• A database that appellants can use to obtain a status on their reconsideration;

• High-level data regarding the types of claims that are being appealed to QICs;

• The percentage of QIC decisions that are favorable, partially favorable, unfavorable, or dismissed;

• The percentage of QIC decisions that are escalated;

• The percentage of QIC decisions that are appealed to OMHA; and

• Own Motion Referrals and Appeals Council decisions.

Additionally, the internal/restricted access section of website shall include:

• Protocols and QIC Technical Direction Letters (TDLs) that QICs use in their operations

(accessible only to CMS, the QICs, and the AdQIC);

o TDL sections shall be organized by TDL Year of Issue, each TDL will be named with the same title CMS provided for the TDL.

o Complete TDL will be accessible in PDF format or other comparable agreed upon and accessible format

• QIC Manuals and forms, training materials, and upcoming training opportunities, etc.;

and,

• Summary of statistics and reports, including but not limited to copies of previously issued and current monthly data report(s) for all QIC activities, and additional ad hoc reports as identified by CMS.

The AdQIC shall continuously monitor the website and modify it with continuous improvements as necessary, upon review and approval from the COR. Any major modifications shall be summarized in the monthly status reports. The restricted portion of the website shall also adhere to CMS Security and Privacy Standards.

In addition, the AdQIC shall ensure that the website is fully compliant with Section 508 of the Rehabilitation Act and the Department of Health & Human Services Section 508 implementation policy. Section 508 requires that all website content be equally accessible to people with disabilities. This applies to Web applications, Web pages and all attached files. It applies to intranet as well as public-facing Web pages. Additional information for 508.

Task 2h: Creating a Referrals Library of Issues

The AdQIC shall create and maintain a referrals library that includes all AdQIC referrals made to the Appeals Council. This referrals library shall be posted to the website and shall include at a minimum: the appellant involved, the Medicare benefit involved, the date and disposition of the ALJ decision, the ALJ appeal number(s), the date of the AdQIC’s referral, the regulatory basis for the referral, the high level category of the referral, the CPT codes of the particular item(s)/service(s) in question, the AdQIC’s high level rationale for the referral, and the resulting Appeals Council decision. The appropriate fields of this referrals library shall be made available, and searchable, on the AdQIC’s website.

The AdQIC shall develop an annual report by January 25th of each year summarizing the referrals the AdQIC has made throughout the last year including any additional observational trends of ALJ decisions over the same time-period. This summary shall consider the resulting Appeals Council and Federal Court (if applicable) decisions resulting from the referral and include statistics from the AdQIC referrals library. At the COR’s request, this annual report shall be made available on the AdQIC’s website.

Task 2i: Create and Maintain Website for Coordination and Prioritization of CMS Contractor Participation in ALJ Hearings

The AdQIC shall create and maintain a central repository to be used by CMS contractors for participation elections in ALJ hearings. The site shall, at a minimum, notify CMS contractors when a new hearing is scheduled, allow contractors to elect their participation type, and minimize need for manual effort to provide OMHA with the elections within specified time frame.

http://www.cms.gov/Research-Statistics-Data-and-Systems/CMS-Information-Technology/Section508/index.html http://www.cms.gov/Research-Statistics-Data-and-Systems/CMS-Information-Technology/Section508/index.html

At a minimum the site shall:

• Notify CMS contractors identified in the NOH when a request for hearing is scheduled within 2 calendar days from receipt of the NOH from OMHA;

• Allow contractors to select their participation role within specified time frame;

• Prioritize contractor responses utilizing the CMS prescribed prioritization process within

1 calendar day of the closing of the Portal Response Period;

• Alert contractors of the prioritization determination (their role) within 1 calendar day of the date the prioritization determination is made; and,

• Respond to OMHA on behalf of all interested/participating contractors for a given NOH no later than 10 calendar days from the date of the AdQIC’s receipt of the NOH from

OMHA.

Other requirements:

• The AdQIC will update their JOAs with all QIC Task Orders to have a proper email notification address or addresses.

Access to the site shall be limited to CMS contractors who participate in ALJ Hearings. The site shall not house any PHI or PII, which will be verified by the AdQIC. User Access Controls shall be provisioned and maintained by the AdQIC and ensure they align with Acceptable Risk Safeguard (ARS).

Task 3: Analysis and Reporting

The contractor shall provide all services related to the analysis and reporting of data for CMS and other Medicare contractors.

A government owned workflow management/electronic case file system called the MAS was developed for use on this program. The AdQIC shall use this system to capture information on all reconsideration cases filed and the AdQIC shall use it to perform data analysis, reporting activities and other duties as detailed in this task order.

At a minimum, the AdQIC shall perform the following routine tasks:

• Analyze individual and cumulative QIC case receipt and disposition data to identify trends and aberrations regarding QIC reconsideration processing and to identify ALJ training and provider, supplier, and beneficiary educational needs IAW section II.A of the USOW.

• Analyze provider, supplier and beneficiary reconsiderations to identify trends and aberrations IAW section II.F of the USOW.

• Enter and maintain the standard list of MACs in the system by adding records for new contractors and revising existing contractor records when necessary.

• Enter and track the location of the physical case file under the ‘case file location screen’ by updating the record when a case file is received from a QIC for storage, received from the ALJ with the decision, sent to the Appeals Council for a referral, sent to OMHA for a late case file request, or forwarded by the AdQIC to any other appropriate entity.

Task 3a: Analysis of Data

On a monthly basis, the AdQIC shall analyze, compare, and trend reconsideration and expedited reconsideration data residing in the MAS database IAW section II.A of the USOW. IAW section II.B.2 of the USOW, the AdQIC shall use this information to recommend:

• Aspects of operations in need of improvement;

• Aspects of the claims processing system in need of improvement;

• Aspects of the appeals process that are in need of improvement;

• Aspects of Medicare program operations that are in need of improvement;

• Provider education initiatives;

• Distribution of appeals;

• Root cause analysis; and,

• Recommendations (business case) for improvement.

Task 3b: Reporting

This section sets forth the AdQIC reporting requirements IAW section II.B of the USOW.

All reports shall be submitted electronically, with hard copy submissions as requested, IAW section II.B of the USOW unless otherwise identified herein. All non-MAS reports shall be submitted in an electronic format compatible with a specified CMS software application (e.g., Microsoft Access, Microsoft Excel, or Microsoft Word, CMS ART or other COR specified CMS System) to the maximum extent possible. Hardcopy report requirements will be designated accordingly.

The AdQIC shall submit the data reports specified below. CMS may request additional reports, or reports in lieu of those identified herein, as required. The AdQIC shall modify reporting formats such as laws, regulations, policies, or other circumstances change.

Task 3c: Monthly Data Reports

The AdQIC shall create, maintain, and update reports in MAS Reporting as necessary. The AdQIC shall report to the COR monthly on the reconsiderations received and adjudicated IAW section II.B.3 of the USOW. The AdQIC shall retrieve this information from the MAS. The Monthly Management Report shall be shall be due by the 15th of the month and shall reflect data on the QICs’ reconsideration decisions during the previous month.

The monthly data report shall organize the data cumulatively and by:

a) Each individual QIC

b) Each individual MAC;

c) Each individual State; and,

d) Each provider type.

The reports shall include the following data, at a minimum (additional reporting elements may be required on this report and will be directed by the COR as necessary):

• The number of reconsideration and expedited reconsideration requests received (cases and claims) during the reporting period;

• The number of cases/claims appealed involving medical necessity issues, statutory exclusions, benefit category determinations, etc.;

• The number of cases/claims received for specific CPT/HCPCS or other procedure codes;

• The number of cases/claims and aggregate dollar amount that are pending within the reporting period. The AdQIC shall group the pending by age;

• The number of cases/claims adjudicated within the reporting period;

• The number/percentage and disposition of each completed case/claims (i.e., affirmed, reversed, partially reversed, withdrawn/dismissed, etc.;

• The service category of cases received (such as a request for payment for emergency care, acute hospital, practitioner services, clinical lab/x-ray, nursing home, therapies, transportation, home health, DME/medical supplies/equipment/Prosthetic devices, outpatient mental health, hospice care);

• Information on the number and disposition of “Own Motion” referrals broken out by QIC and MAC;

• Information on emerging patterns and/or clinical issues pertinent to the reconsideration process;

• Data on work performance, to include information on the timeliness of the processing of reconsiderations and expedited reconsiderations, including average time to process reconsiderations and expedited reconsiderations;

• Information on the number of requests for an ALJ hearing (cases/claims), and information on completed/returned ALJ cases (such as the number/percentage of cases affirmed, reversed, dismissed, etc. broken out by QIC and MAC). The AdQIC shall also report on the number of cases promoted from the QIC to the ALJ level;

• The participation of Medicare contractors in ALJ hearings and the outcome of participation.

• Information on the number of requests for an Appeals Council review, and information on completed reviews (such as the number/percentage of cases affirmed, reversed, dismissed, etc.);

• Information on the number/percentage of completed reconsiderations/expedited reconsiderations that involved physician review; and,

• Identify the top five (5) percent of providers, suppliers, or other entities or individuals who are submitting reconsideration requests.

The AdQIC shall make the reports available in monthly, quarterly and/or annual formats as requested by CMS.

Task 3d: Dissemination of Data Reports

The AdQIC shall distribute QIC monthly data reports including current and cumulative data, electronically no later than the 15th of each month for the previous months’ effort IAW section II.B and II.B.3 of the USOW.

Task 3e: Ad Hoc Reports

During the task order, the AdQIC may be required to prepare special reports on specific issues or analyses for CMS IAW section II.B.3 of the USOW. For example, prior to a routine CMS monitoring visit to the AdQIC or a QIC or for a CMS CO/RO conference on specific coverage policy, the AdQIC may be instructed by the COR to generate a report on specific appealed service category (e.g., SNF services) and prepare a report or analysis regarding the number and types of reconsiderations received and adjudicated. The format of each report will vary with need, but can be electronic (i.e., Microsoft Excel or PowerPoint, PDF, CSV, etc.) or hard copy.

The due date for the completion of a requested ad hoc report will be determined by agreement of the COR and the AdQIC.

The AdQIC shall also respond to ad hoc requests for reports or assistance in generating reports from the QICs, MACs, RACs, and UPICs, and will respond to business questions from other agencies/components as approved by CMS.

Task 3f: Notifications

The AdQIC shall notify contractors of the following events on a weekly basis unless noted:

• RAC appeals dispositions for RA cases decided by the Appeals Council;

• MAC of the promotion of MAC cases to OMHA;

• OMHA of cases decided that have not been sent to the AdQIC (bi-weekly); and, •

OMHA of ALJ decisions that require clarification prior to effectuation (bi-weekly).

The AdQIC shall build and maintain reports in MAS Reporting for the purpose of notifying contractors of the following events:

• RACs of QIC claim dispositions of RAC cases;

• RACs of the promotion of RAC cases to OMHA;

• RACs of appeal dispositions of RAC cases decided by OMHA;

• UPICs of QIC claim dispositions of UPIC cases; and,

• UPICs of the promotion of UPIC cases to OMHA.

Task 3g: User group support

The AdQIC shall participate in and chair the following periodic meetings:

• Chair the MAS User group;

• Chair the Cognos reporting call;

• Chair the All-QIC call;

• Participation in MAS Technical and Business Internal Work Groups; and,

• Participation in the MAS Change Control Board (as requested).

Task 4: Review of ALJ and Appeals Council decisions

The AdQIC shall scan and digitally store administrative case files returning from the ALJ hearing offices post-decision and review these decisions for possible referral to the Appeals Council. If a referral is not sent to the Appeals Council, the AdQIC shall send an effectuation notice to the MAC within 10 calendar days of receipt of the ALJ decision. The AdQIC shall request clarifications of ALJ decisions so that they can be effectuated. AdQIC shall review Appeals Council decisions for reversal of ALJ decisions and / or liability change. The AdQIC shall forward an effectuation notice to the MAC within 10 calendar days of receipt.

The AdQIC shall provide an ALJ disposition report to the QICs monthly.

Task 5: Agency Referrals of ALJ decisions

The AdQIC shall review all partially favorable and favorable ALJ decisions to recommend Appeals Council reviews IAW USOW section III.H.2. The AdQIC shall also review all unfavorable ALJ decisions to capture hearing information and liability for payment.

Task 6: Records Management

The contractor shall adhere to the requirements set forth at Appendix C, Records Management Program.

As directed by CMS, when a QIC contract transitions from one entity to another, the AdQIC shall receive, store, and retain departing QIC contractor’s jurisdiction universe of appeals documentation images adjudicated during that QIC’s period of performance. Storage medium and transfer shall be discussed in advance by the AdQIC, CMS, and the departing QIC contractor. The storage and transfer shall meet all CMS security requirements including but not limited to full encryption, secure delivery, and secure storage.

Destruction of documentation and storage mediums shall be at the direction of CMS, at the end of a period of performance, or in accordance with current record retention or closeout requirements.

In addition, as needed by new QIC, the AdQIC shall update any documents as identified as missing from MAS by the current holder of the QIC contract.

Task 6a: Forwarding case files to OMHA on late filed requests

Forwarding case files to OMHA is the primary responsibility of the QICs. However, there are occasions where an appeal request that is filed late is accepted for good cause and the file will need to be retrieved for the hearing.

The AdQIC shall retrieve and forward any case file that is requested by OMHA Central Docket to the appropriate OMHA field office within 5 calendar days of the request. This 5-day timeframe applies only to cases that are still in-house at the AdQIC facility in digital format.

Unless a rare circumstance has occurred and a dated paper case is requested, please consult the

COR.

Task 6b: Case File Requests

The AdQIC shall respond to valid requests for case files and provide requested documentation.

The AdQIC shall contact CMS COR if there is a question regarding a specific case file request.

Requests can come from but are not limited to MEAG, DAO, OMHA, the Council, OGC, DOJ, etc.

Task 6c: Party Case File Requests

The AdQIC shall respond to requests for Closed OMHA case files made by valid Parties to the appeal (405.1042 (b)).

Upon receipt of a request for the closed OMHA case file from a 3rd Party, CMS or OMHA representative, the AdQIC shall at minimum:

1. Validate that the 3rd Party requestor is a valid party to the appeal in accordance with (405.1042 (b)) and the Closed OMHA Case File Request Protocol.

2. Provide the requested information to the valid 3rd Party requestor within 20 business days. Note: If there are instances in which a requested case file is particularly large, the AdQIC shall contact the COR to discuss an amended timeframe for production.

3. Provide the requested documentation in a secure manner via secure zip email, encrypted thumb drive, efax, etc.

4. Refer to 3rd Party Request Protocol Document or as direct by the COR

If upon researching the request, the AdQIC finds that the case is not closed at OMHA, pending at OMHA, or pending with the DAB, the AdQIC shall refer the requestor to OMHA and/or the

DAB.

Optional Task 7: Report to Congress

The AdQIC shall draft and finalize an annual report to Congress describing the number of appeals for the previous year, identifying issues that require administrative or legislative actions and including any recommendations with respect to such actions. The AdQIC shall include in the report an analysis of the reconsideration decisions issued by the QICs, with particular attention paid to inconsistent decisions and an analysis of the causes of any such inconsistencies. The first draft of the report will be 30 calendar days after this optional task is exercised. A final report to congress shall be submitted to the COR within 15 calendar days of receipt of the CMS comments.

Optional Task 8: Scanning Appeals Case Files

In coordination with CMS’ efforts to transition to a fully electronic appeals case file, CMS must also address paper case files. In accordance with the document retention requirements listed in Appendix C, an electronic image of a paper case file is an acceptable solution for long-term data retention. With most of this task having been completed, the need to scan any documentation should be nominal. The contractor shall also coordinate with the QICs and OMHA to determine the feasibility of receiving any previously imaged appeals case files to prevent duplication of efforts.

As part of this optional task, the contractor shall:

1. Receive paper case files from OMHA or the electronic images of the case files from the respective QICs, beginning with the more recent boxes sent.

2. Scan, index, and validate that the images are exact duplicates of the original case files into either PDF or TIFF file formats.

3. Upload those images to the CMS ECM system utilizing the MAS document importer, or any other compatible method that will allow those images to be accessed through the appropriate MAS appeals record.

4. Destroy the original paper case files in accordance with the federal records requirements listed in Appendix C, once the imaged copy has been validated and appropriately uploaded into the CMS ECM system. If the contractor obtains imaged records from the QICs for all appeals case files in a box at the long-term storage facility, the contractor shall request that the box be destroyed by the long-term storage facility.

5. In addition to the above activities, the AdQIC shall store/retain the backup images of outgoing QIC contracts, as directed by CMS, until the images can be verified in MAS and/or until otherwise directed by CMS.

Optional Task 9: Coordination, Reporting, and Education for Medicare Contractors

There are many CMS contractors outside of the QIC program that have an impact on the Medicare appeals process. The AdQIC shall provide introductory and on-going training for Medicare contractors on an as-needed basis, as directed by the COR. This task will be exercised whenever a need for Medicare contractor education arises.

Optional Task 9a: Providing Appeals Education for Medical Review (MR) staff at the Medicare contractor.

The AdQIC shall provide both introductory and continuing education for all current and future contractor employees on appeals issues.

The AdQIC shall provide one teleconference per newly awarded contractor (when applicable), approximately 15 contractors, as requested for the purpose of introductory education. The AdQIC shall coordinate with each contractor to schedule the introductory education conference.

The introductory education shall include, at a minimum, education on the administrative appeals process, the reopening regulations, components of overpayment demand letters, changes to the appeals program, and writing position papers for ALJ hearings. Three weeks prior to the scheduled educational session, the AdQIC shall provide to the COR an agenda for approval as well as copies of handouts and educational materials if requested. The AdQIC shall track attendance and provide the COR with a list of attendees following each session.

The AdQIC shall also provide one in-person (or remote) training session for all contractors per year to provide continuing education. Continuing education, at a minimum, shall include education on supporting contractor determinations throughout the appeals process, appeal reversal trends, administrative issues, and other Ad-hoc appeals issues. Three weeks prior to the continuing education session, the AdQIC shall provide to the COR an agenda for approval as well as copies of handouts and educational materials if requested. The AdQIC shall track attendance and provide the COR with a list of attendees following each session as needed.

Optional Task 9b: Contractor Data Collection and the Data Warehouses

The AdQIC shall collect all contractor procedural and claim review information from the MAS to provide standardized appeal reporting on contractor appeals. On a weekly basis the AdQIC shall:

6. Obtain from the contractor Data Warehouse (DW) all necessary claim numbers, providers, dates of service, and any other identifying information to accurately track the particular service.

7. Provide to the DW the initiation and disposition of appealed claims by the QIC, ALJ and

Appeals Council.

8. Provide level two and level three contractor appeal status via the website. Level three cases should be searchable by MAS shell number as well as ECAPE appeal number.

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