OM Part A West SOW.pdf

Attachment J-1 Statement of Work Requirement No. XXX

Solicitation No. XXX

QIC TASK ORDER - Part A West Workload

STATEMENT OF WORK

I. SCOPE

The contractor shall provide adjudication services in support of the Medicare, Medicaid, and Children’s Health Insurance Program Benefits Improvement and Protection Act of 2000 (BIPA), Public Law 106-554, Subtitle C - Changes in Medicare Coverage and Appeals Process, Section 521 Revisions to Medicare Appeals Process. More specifically, the contractor shall act as a “Qualified Independent Contractor” (QIC) responsible for conducting reconsiderations of initial Medicare claims determinations in the jurisdiction identified in Section I.A below.

A. Background

The QIC shall be responsible for all reconsiderations requested as a result of Medicare Administrative Contractors (MACs) redeterminations of Medicare Part A and Part B of A claims. This workload includes processing reconsideration requests for, at a minimum, hospital inpatient, home health, skilled nursing home, hospice, and other Part A services and claims. It also includes institutional claims which are paid from the Part B Trust Fund (sometimes referred to as “Part B of A”). The QIC shall also be responsible for the expedited reconsideration workload comprised of, at a minimum, service termination and hospital discharge reviews performed by Quality Improvement Organizations (QIOs). It shall be noted that the QIC is also responsible for reconsiderations based on “initial determinations” regarding Medicare Secondary Payer (MSP) recovery claims against beneficiaries or providers/suppliers where the redetermination was processed by a MAC. Such recovery claims against beneficiaries routinely include both Part A & Part B claims.

The Part A West jurisdiction is reflected in the table below.

Part A West QIC Covered States

Part A - West

Washington, Idaho, Montana, North Dakota, South Dakota, Iowa, Missouri, Kansas, Nebraska, Wyoming, Utah, Arizona, Nevada, California, Alaska, Hawaii, Oregon, Kentucky, Ohio, Indiana, Illinois, Minnesota, Michigan, Wisconsin, Guam, Northern Mariana Islands, American Samoa

The claims estimates in Section B of this task order (TO) include, but not limited to: standard, expedited, Recovery Audit Contractor (RAC), Supplemental Review Contractor (SMRC), MSP, Unified Program Integrity Contractors (UPIC), inpatient PPS hospital, long term care, and inpatient hospital discharge appeals.

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The workload estimates are delineated by period of performance (POP). Claims received shall be billed against the POP in which they are received even if the case/claims are completed in a subsequent POP. For example, a claim received during the 12-month Base Operational Period shall be billed against the appropriate Sub Line Item Number (SLIN) for the Base Period even if the case/claim is not completed/closed until Renewal Period I.

In addition, each claim may only be billed to the TO once. Any and all subsequent actions on the claim, including, but not limited to, reopenings, corrected letters, Administrative Law Judge (ALJ) remands, and corrected/vacated dismissals (including claims that were previously dismissed for no redetermination), will not be reimbursed separately.

For any cases that contain more than 250 claims, the Part A West QIC shall contact the Contracting Officer’s Representative (COR) to discuss utilizing statistical extrapolation for that case in accordance with Task 11 below.

The Part A West workload includes responding to a minimal number of reopening requests, ALJ remand orders, inquiries, and/or litigation holds on cases decided by the outgoing QIC. The Centers for Medicare & Medicaid Services (CMS) does not anticipate a large volume of appeals activities/inquiries related to these functions.

In the event the QIC receives a reopening request and/or ALJ remand order on cases in which it has not previously decided, the QIC may bill for such claims under the appropriate SLIN for this TO given it has not previously been paid for those claims under this and/or any other QIC TO.

This is a Firm-Fixed-Price (FFP) task order. The QIC shall perform tasks as funded and authorized by exercise of award terms.

The QIC shall include all costs associated with any activities related to reconsideration activities as defined in this SOW (including but not limited to, Medicare Appeals System (MAS) activities, adjudicating claims, mailroom activities, responding to telephone and written inquiries, reopenings processing including previously dismissed appeals, ALJ activities, responding to remands, etc.) in the unit cost per claim proposed in the respective SLINs by POP.

Expedited Reconsiderations

The QIC shall perform expedited reconsiderations in accordance with section 1869(c)(3)(C)(iii) of the Act, 42 CFR Part 405 Subpart J, USOW section III.G, and the associated protocol(s). The QIC shall make every effort to complete all expedited reconsiderations within the 72-hour timeframe, which includes accepting and processing requests on weekends, as necessary. Per 42 CFR 405.1204(c)(3), the 72-hour time period does not commence until the QIC receives the medical records and other evidence needed to make the expedited reconsideration.

Per 42 CFR 405.1204(c)(1), on the day the QIC receives the request for an expedited reconsideration, the QIC shall immediately contact the QIO for medical records. The expedited

Solicitation No. XXX reconsideration request is considered to be received on the date and time the phone call is made by the beneficiary, the date and time the telephone message was left by the beneficiary, or the time the mail request is received at the QIC's mailroom. The QIC shall be available to accept beneficiary telephone request on all days, including weekends and holidays. Exceptions will only be allowed for acts of God (adverse weather conditions, roads closed, blizzards, etc.). In these situations, the QIC will be deemed to be unavailable to accept requests and all requests received will be considered to be received on the next day of operation for reconsideration timeliness purposes.

B. Purpose

The purpose of this Task Order (TO) is to conduct standard and expedited reconsiderations of redeterminations issued by MACs and/or QIOs in this jurisdiction (as defined above). The outcomes of this TO shall include, at a minimum:

• Timely, accurate, consistent, and high-quality adjudication of reconsiderations and expedited reconsiderations of initial determinations using established protocols;

• Case management and documentation, including electronic case management/document imaging, into the MAS;

• Timely and accurate collection and transmission of information regarding the receipt, workflow, and disposition of reconsiderations and expedited reconsiderations via the MAS;

• Timely and accurate document imaging to produce a complete second level electronic case file;

• Communication of decisions about appeals with appellants and other parties to the appeal;

and,

• Participation and coordination with other entities in the Medicare appeals chain including, but not limited to, CMS, the Administrative QIC (AdQIC), other QICs, MACs, QIOs, RACs, UPICs, SMRCs, the Benefits Coordination & Recovery Center (BCRC), the Commercial Repayment Center (CRC), the Office of Medicare Hearings and Appeals (OMHA), and the Medicare Appeals Council within the Departmental Appeals Board (herein after Appeals Council), as well as, the Department of Justice, the Office of Inspector General, and the Government Accountability Office, as needed to support the activities as outlined in this

SOW.

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)

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CD-ROM Drive For Installation of Software Software Microsoft Office 2016 or latest version

Java version 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.

• The following are the minimum specifications of the CMS security policies that must be maintained:

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

CMS Interconnection Security Agreement

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

CMS Data Use Agreement To be completed by the QIC as an Organization 30 calendar 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 schedule Authority to Operate (ATO) and Security Control Assessment or Adaptive Control Testing (ACT) Schedule as defined by the System’s Information System Security Officer

(ISSO)

CMS Acceptable Risk Safeguards

(ARS)

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

Acceptable Risk Safeguards

(ARS)

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

Note: The Part A West QIC shall undergo a security audit and obtain an ATO within 6 months of contract award.

II. REQUIREMENTS

The QIC Umbrella SOW (USOW) is incorporated into this 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 QIC shall furnish all of 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 TO SOW for Jurisdiction Part A West.

The QIC shall perform all of the requirements of the QIC umbrella SOW EXCEPT FOR THE

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FOLLOWING SECTIONS:

I.A.2—Medicare Part C and the PACE Program I.A.3—Medicare Part D I.A.4—Quality Improvement Organizations I.A.6—The Medicare Part C Appeals Process I.A.7—The Medicare Part D Appeals Process II.B.2—Future Enhancement Report II.B.6—Award Fee Plan Self-Assessment II.F—Administrative Services II.F.1—Protocols II.F.2—QIC Manual II.F.3—Training III.H.1—ALJ Hearings III.H.2—Appeals Council Review

VI—Award Fee Plan

A. Phases

The period of performance is as follows:

Base Period-Operational: January 1, 2026 – December 31, 2026 Renewal Period I: January 1, 2027 – December 31, 2027 Renewal Period II: January 1, 2028 – December 31, 2028 Transition Out (optional): January 1, 2029 – April 30, 2029

Note: The QIC shall no longer receive/process new reconsideration requests received on or after January 1, 2029. The QIC shall process reconsideration requests received on or before December 31, 2028 in accordance with existing regulatory and/or SOW requirements.

A.1 Operational Phase

The operational phase shall commence on January 1st, 2026. During the operational phase, the QIC, at a minimum, shall:

• Adjudicate accurate, high quality, consistent, and timely second level Medicare appeals;

• Request and receive appeals case files from the Level 1 redetermination contractors;

• Expeditiously and accurately scan and upload all document images and related case file information (including all related correspondence) into the MAS;

• Expeditiously and accurately update MAS in accordance with the MAS QIC Required

Fields** (Appendix C MAS QIC Required Fields attachment is current as of the date of this RFP and is subject to change);

• Forward case files to OMHA in accordance with the attached QIC/OMHA Memorandum of Understanding (MOU) (Attachment J-3 to this TO);

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• Participate in ALJ hearings as a party or a participant;

• Respond to a minimal number of post-transition reopening requests and ALJ remand orders on cases decided by the outgoing QIC;

• Respond to written and telephone inquiries related to reconsiderations activities conducted by the current and previous Part A West QIC in a timely and accurate manner;

• Identify, report, and respond to issues or inquiries that require CMS input in an expeditious, timely, and accurate manner;

• Comply with panel of clinical experts’ requirements;

• Review and respond to reconsideration requests in the language in which it was received

(e.g., a reconsideration request received in Spanish shall have all related correspondence, such as the acknowledgement letter and reconsideration decision letter issued in Spanish).

The appeals case file shall also include a copy of the English version of the respective correspondence/letters. In addition, as requested by parties or CMS, the QIC shall respond to related inquiries in an alternate language;

• Participate in training conducted by the AdQIC and as requested by CMS;

• Provide feedback to the AdQIC on the development of protocols;

• Provide accurate and timely effectuation information to MACs; and

• Provide feedback to the MAS system maintainer

B. Specific tasks to be performed: The following tasks are in addition to those already defined in the umbrella SOW.

Task 1: Initial Meeting/Kickoff Conference

Meeting with CMS:

In preparing to implement new requirements, the QIC shall arrange an initial meeting/kick-off conference with CMS. This meeting shall be held no later than 15 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 QIC shall provide CMS with information regarding the new mailing address (postal and courier information) and/or other relevant information as to where new reconsideration requests shall be submitted during the operational phase.

Following the meeting, the QIC 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 MACs:

The QIC also shall have an initial meeting/kick off conference call with the MACs in the applicable jurisdictions. This meeting shall occur no later than 15 calendar days after TO award and shall be held via teleconference or online medium compatible with CMS computer systems.

At this initial meeting, the QIC shall work with the MACs and provide, at a minimum, the following information:

• A list of workgroup members;

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• A list of all deliverables necessary to ensure a smooth transition of documentation, if applicable, between the MACs and the QIC and the dates upon which these will be sent to the QIC;

• A draft JOA; and,

• The QIC shall work with the MACs to determine the appropriate types and timing of communication and education activities needed to inform beneficiaries and providers about the QIC’s role.

CMS will notify the QIC, upon task order award, if an initial kick off meeting will occur between CMS, the QIC, and OMHA. The QIC shall work through CMS to establish the meeting date, time, and location for the OMHA kickoff meeting.

The QIC shall be responsible for providing draft meeting minutes and deliverables to the COR for all activities no later than three (3) business days following each meeting. Final meeting minutes and deliverables listings shall be provided to all participants within 3 business days of receipt of any comments from the COR.

Task 2: Project Plan

Task 2 activities are only applicable if the Transition-In phase is exercised.

Task 3: JOAs & CMS/OMHA/QIC MOU

The AdQIC has developed JOA templates relative to the AdQIC/QIC, QIC/MACs, QIC/QIOs, QIC/UPICs, QIC/BCRC, QIC/CRC, QIC/SMRC, and QIC/RACs. The QIC shall utilize existing JOA templates and/or other related documents to continue established communications with the respective CMS contractors.

AdQIC/MAC/QIO/UPIC/RAC/SMRC/BCRC/CRC JOAs:

The QIC/MAC JOAs shall include language indicating that the appeals case file will be obtained via electronic promotion of the level one appeal record within the MAS. The QIC/MAC JOA shall include language to address situations in which the MAS is down or otherwise unavailable for short term and/or long-term periods of time. In addition, the JOA shall include language to address processes and procedures for providing case files that are not in the MAS due to the redetermination having been processed prior to the level one MAS implementation and/or the rare instance that the file is otherwise not available in the MAS.

• Establishing New JOAs, as applicable: Should the QIC not already have established JOAs with the AdQIC/MACs/QIOs/UPICs/RACs/SMRCs/BCRC/CRC, the QIC shall submit draft written JOAs to the COR and the relevant party to each JOA for comment no later than 30 days prior to the start of the operational phase. For purposes of this section, the relevant party to the JOA is defined as the MAC, QIO, UPIC, RAC, SMRC, BCRC, CRC, and AdQIC. The QIC 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 QIC

Solicitation No. XXX shall obtain the appropriate signatures from the QIC and 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 QIC shall furnish a copy of the signed JOA to the COR, Contract Specialist (CS), and the relevant party.

• Updating Existing JOAs, as applicable: If the QIC has existing JOAs with the relevant parties noted above, the QIC 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 QIC shall obtain the appropriate signatures from the QIC and 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 QIC shall furnish a copy of the signed JOA to the COR, CS, and the relevant party.

The JOAs shall be maintained by the QIC to provide a documented means of identifying roles and responsibilities of the QIC, the AdQIC, the UPICs, the QIOs, the RACs, the SMRC, the BCRC, the CRC, the OMHA, and the MACs.

The QIC shall update the AdQIC/MAC/QIO/UPIC/RAC/SMRC/BCRC/CRC JOAs on an annual basis on January 1st (or a mutually agreeable time between the respective parties, 1 time per year) or more frequently if significant changes warrant an interim update, or on a date that is mutually agreeable between the two entities. In addition, if an annual update is mutually agreeable between the QIC and the respective entity, the QIC has the discretion to update this deliverable on an annual basis. However, the QIC shall notify the COR within 5 calendar days of agreement with the respective entity to follow an annual update process and identify the mutually agreeable timeframe in which this update will occur so that the COR can update the due date(s) in CMS ART (or other specified CMS Deliverable System of Record) accordingly. The QIC shall track changes through an appropriate means from the previous document and distribute changes to the relevant parties.

If during the mutually agreeable update period, no changes are identified, the QIC shall submit a statement to this effect to the COR via CMS ART (or other specified CMS Deliverable System of Record), or any mandated system as directed by the COR, and the relevant parties. The JOAs shall be uploaded into CMS ART (or other specified CMS Deliverable System of Record) and distributed to the CO, COR, and the relevant party to each JOA.

The JOAs will not be incorporated into TO contracts as this document is a mutual agreement between the QIC 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 QIC and the relevant party will first attempt to resolve the above issue(s). If they are unable to come to a resolution, the matter will be raised to the respective CORs. In the event that a dispute between the QIC and the relevant party to the JOA cannot be resolved by the COR and related parties within 30 calendar days (excludes budget issues), the QIC shall direct the issue in writing to the 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 QIC 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.

In addition to the requirements noted above, the JOA shall also include, at a minimum:

• A description and documentation of process/workflows that illustrate how the QIC and the relevant party (MAC/AdQIC/UPIC/RAC/SMRC/BCRC/CRC/QIO/OMHA) intend to interact with one another to complete each of the tasks outlined in the TO on a daily basis;

• Risk mitigation of duplicate medical documentation requests at various levels of the appeals process;

• Identify the JOA participants;

• Describe the roles and responsibilities of the Part A West QIC and the relevant party;

• Clearly define the dispute resolution process;

• Describe communication between entities regarding CMS changes;

• Include systems information and how data will be shared including imaged appeals case files;

• Include training and education;

• Include how requests for information will be processed;

• Include Freedom of Information Act (FOIA) and Privacy Act responsibilities;

• Include JOA workgroup meetings;

• Include the Protocol Refinement Committee meetings (as applicable); and,

• Contain other items identified by CMS, the QIC, and/or the relevant party.

Part A West QIC/CMS/OMHA/MOU:

The QIC also shall be responsible for complying with the requirements as outlined in the attached CMS/QIC/OMHA MOU (see Attachment J-3). The OMHA MOU shall outline the policies and procedures for the QICs interactions with OMHA. CMS shall work with OMHA and the QIC to review the MOU that was included with this RFP and update it on an annual basis. .

While CMS will lead the negotiations of any changes to the OMHA/CMS/QIC MOU, the QIC shall be responsible for expeditiously reviewing any suggested changes and providing feedback to CMS. Additional information regarding this process shall be provided upon TO award.

Reports to CMS of QIC non-compliance with the terms of the OMHA 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 4: Monthly Reporting

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Monthly Progress Report:

In addition to the general reporting requirements set out in the umbrella SOW, QIC shall submit a Monthly Progress Report of its monthly activity/workload and a Case File List Report via CMS sponsored deliverable application: https://arts.cms.gov/CMSART/.

Monthly progress reports shall be submitted into CMS sponsored deliverable application by the 15th of each month. The COR and the Part A West QIC shall agree to the content and format of the Monthly Progress Report.

The Monthly Progress Report shall include, at a minimum:

• Prior month’s activities by task and activity;

• Report on the efficacy of the JOA;

• Summaries of meetings and areas of concentration for the upcoming month;

• Issues of concern that require CMS’ action;

• Updates with regard to quality assurance;

• Updates regarding receipt/response to ALJ remands;

• Any unresolved issues from the prior month;

• Workload report (submitted in the CMS ART System (other specified CMS Deliverable

System of Record) only);

• Workload narrative support if necessary;

• Workload projections (i.e., tracking and projecting claims received and claims remaining on respective SLINs).

• A listing of any cases that were more than 250 claims, an indication of when the appeal was received, when CMS was notified of the appeal, when the QIC received notification from CMS and the appellant to begin statistical sampling, if applicable, and any other information relevant to these activities;

• A listing of any cases that were untimely in meeting the imaging case file uploading requirements as required under Task 10. In addition, the QIC shall also include an indication of the system or other issue(s) causing the delay in meeting this requirement and potential resolution;

• A listing of any cases that surpassed the sixty (60) calendar day decision making timeframe;

• Feedback/discussion regarding any trends in the appeals process and recommendations for policies that may need changes/clarification;

• A listing and discussion of any congressional, regional office, or COR related inquiries received during the prior month, the related case, the actions taken and/or the current status.

Information submitted shall also include a self-assessment, as applicable, for process improvements on any issues identified in this process;

• Information pertaining to the total number of written appellate inquiries received during the month, including the average time for the QIC to resolve the inquiry. Written inquiries should be broken out as routine (e.g. status inquiries) and complex (inquiries requiring investigation and/or substantive responses).

• Information pertaining to the total number of telephone appellate inquiries received during the month, including the average time for the QIC to resolve the inquiry. Telephonic https://arts.cms.gov/CMSART/

Solicitation No. XXX inquiries should be broken out as routine (e.g. status inquiries) and complex (inquiries requiring investigation and/or substantive responses).

• A breakout of the volume of additional documentation requests per month/POP;

• A breakout of the documentation requests by billing provider and other providers;

• Data regarding the responsiveness of the requests for documentation; and,

• Innovations to Improve the Medicare Appeals Program as required in Task 6.

In addition, the QIC shall regularly monitor the workload (appeals/claims) received in the respective period of performance and proactively identify if the received workload may or will exceed exercised CLIN/SLIN volumes (e.g., the volume of claims exercised on a particular SLIN for a particular period of performance). If the contractor identifies a potential overrun, they shall notify the CO, Contract Specialist (CS), and COR, in writing, within three (3) business days of identification that it may or will exceed exercised CLIN/SLIN volumes. The contractor shall take additional steps and actions to ensure oversight and management of the claim volumes received to ensure adequate notification to the CO, CS, and COR. If exercised claim ceilings are exceeded without adequate notification to CMS, there may be a delay in the availability of additional funding for the respective contracts. Further, CMS may consider the cause for the failure for adequate notification to determine if it is performance related.

The QIC shall also notify the CO, CS, and COR, in writing, within one (1) week of when the invoiced billing hits 50 percent of the exercised costs in a given period of performance and again once they have billed 75 percent of the exercised cost in a given period of performance.

The COR may request that additional information is submitted with the monthly report as necessary.

Case File List Report:

In addition to the general reporting requirements set out in the USOW and this task, the QIC also shall submit a Monthly Case File List Report on the 20th of each month that identifies the reconsiderations completed in the previous month. Included in this report should be a listing of cases, claims, and dispositions completed during the month, the date the cases were received, and the number of claims included, and the date the case was completed and closed in MAS. This case file listing report shall provide the documentation needed to support the cases billed for the month’s activities on the monthly voucher including a reconciliation of claims billed as compared to MAS data for the respective month invoiced. Contractors may only bill for claims that are closed in the MAS. The CMS shall provide additional details regarding this report upon TO award and/or as required upon future modifications.

All significant CMS ART (or other specified CMS Deliverable System of Record) changes shall be communicated via News/Updates feature of the CMS ART System.

Task 5: Data Analysis/Improving the Medicare Appeals Process

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The QIC shall analyze and trend their reconsideration decisions utilizing the standard reports in the MAS, AdQIC data/reports (as applicable), and/or other materials, as appropriate, to provide the COR, MACs, QIOs, UPICs, RACs, SMRCs, BCRC, CRC, and/or other CMS contractors within the QIC’s jurisdiction with information regarding the appeals activities in the respective jurisdiction. The QIC shall communicate substantial findings regarding the appeals activities and/or other issues on a semi-annual basis. This report may include identifying areas in which for example, additional education is necessary from the MACs, problems/issues in the appeals process, etc. This analysis shall also include a review of completed cases to determine the consistency of the decision-making process by appeal type. The QIC shall solicit feedback from the relevant parties to determine the specific contents to be included in this report. The QIC also shall use such findings to improve their operations and the appeals process. Note: providing trending reports to the UPIC does not replace the USOW requirement regarding fraud referrals. The QIC shall comply with the requirements regarding fraud referrals as outlined in USOW section III.B.

Task 6: Innovations to Improve the Medicare Appeals Program

The Part A West QIC shall develop innovations and/or other activities to improve the Medicare fee-for-service appeals process and reduce the volume of future appeals to the ALJ and/or address the backlog of appeals, as applicable (e.g., policy recommendations, operational innovations, etc.). The QIC shall submit a minimum of one (1) innovative idea/recommendation directly to the COR per year. This innovative idea/recommendation should also appear as an appendix to the final Monthly Progress Report of the POP (see Task 4). The proposed innovation, as submitted in the appendix, shall include at a minimum:

• Details regarding the proposed innovation/approach;

• Supporting data and/or other information utilized to develop the proposed innovation/recommendation;

• Information regarding what changes, as applicable, are needed to implement (e.g., SOW changes, systems changes, procedural updates, policy, etc.);

• Implementation timeframes;

• Cost impact, as applicable; and,

• Any other information as requested by the COR after review of the proposed innovation.

The CMS shall evaluate the quality and effectiveness of the proposed innovations when considering the QICs performance in the respective POP.

Task 7: Website

The QIC shall develop and go live with a public facing Part A West website no later than 60 calendar days after the TO award. After development, the QIC shall maintain the website. The QIC 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. The Part A West QIC shall submit to the COR(s) the website content prior to going live for review/approval.

The website shall include, at a minimum, the following information:

• Easily accessible/identifiable information regarding the contract transition, if applicable;

• QIC’s name and jurisdiction;

• QIC’s contact information (including telephone number and mailing information); and

• Reconsideration request requirements as established in 42 CFR §405.964.

Section 508 requires that all Web site 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 can be found at the following link:

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

Task 8: Telecommunications

The QIC is required to obtain (or simply maintain) a CMSnet connection to the CMS network to connect to the MAS.

The CMS, through the telecommunications contractor, will provide and install routers used for the Wide Area Network (WAN) connectivity. The QIC is responsible for the Local Area Network (LAN) configuration to those routers, including any circuits, cables, routers, switches, servers, or any other device and/or software necessary to connect to the CMS infrastructure.

The QIC shall install all necessary telecommunication software and have the ability to transmit and receive data via standard telecommunication parts and protocols including, at a minimum, ports 80 and 443.

The QIC shall submit a request for telecommunications services, as needed, through their COR and the OIT COR. The COR shall provide the QIC with the documentation that needs to be completed upon request. The QIC shall submit the completed documentation to their COR and OIT COR. The QIC shall participate in regular teleconferences with the Office of Information Services (OIS) and the OIT COR to ensure that all telecommunications needs are communicated accurately and in a timely manner in order to ensure the most prompt installation.

Additionally, the QIC shall ensure arrangements have been made for the local phone company and/or other telecommunications staff to have access to buildings to install lines and/or equipment prior to the CMS telecommunications company installation, should additional connectivity/connections be necessary during the TO period of performance.

Task 9: Medicare Appeals System (MAS) 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

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In accordance with USOW section III.A.4, the QIC shall enter all reconsiderations and related case file documentation within the QIC’s jurisdiction into the MAS promptly upon receipt and continuously update the MAS record throughout the adjudication process in accordance with the USOW and TO SOW. This task further defines the following MAS entry requirements that, at a minimum, the QIC shall perform:

• Timely and accurately enter data into the MAS required fields as provided in Appendix C to this SOW; and

• Populate the claims data within MAS exactly as the claims are populated in the Medicare shared systems utilizing the MAS claim interface, or manual data entry when the claims interface is unavailable. This includes entering claims data on cases that are dismissed if the claims can be identified by the QIC.

Task 10: Document Imaging into MAS

The QIC shall coordinate and implement a document imaging system designed to produce a complete electronic second level appeal. The QIC shall image all medical records or appeal records and load them into the MAS using the MAS document importer (as directed below). The MAS document importer allows both .pdf and .tiff document file formats. Once imported, these documents can be viewed through the MAS custom image viewer.

Document imaging shall include scanning a case in its entirety when it reaches the QIC, performing Quality Assurance (QA) on scanned images, indexing the scanned images appropriately, and using these scanned images to make a decision on the appeals. The QIC shall coordinate this effort with CMS to ensure a seamless transition to complete electronic appeals processing.

Coordination of this effort shall include the following, at a minimum:

• The QIC shall upload all images/case file documentation into MAS within fifteen (15) business days after the date of the reconsideration decision letter. In big box cases, the QIC shall upload all images to MAS within thirty (30) business days after the date of the reconsideration decision letter. The QIC shall notify the COR and include information in the monthly report regarding any cases that the QIC is unable to successfully load the imaged documentation in accordance with this task. Note: big box cases are defined as 40 claims or more;

• Purchasing high volume scanners, as needed;

• Developing workflow processes for imaging and indexing (minimum indexing items shall include appeal number, claim number/ID, and beneficiary Health Insurance Claim Number (HICN)/Medicare Number (or Medicare Beneficiary Identifier (MBI), as it may be identified in MAS until updated), and all second level appeal information;

• Installing scanners, workstations, relevant software, and T1 line connectivity;

• Developing an electronic document management system to store imaged appeals case files and load them into MAS;

• Using these scanned images to make decisions on appeals; and

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• Adhering to CMS’ standards for information security, including the CMS ARS.

This system shall adhere to: all CMS IT security standards for sensitive data, all CMS security requirements in the ARS, all CMS document retention policies, and be able to provide timely access to the images for case adjudication purposes.

The QIC shall also submit a contingency plan for imaging failure in accordance with USOW Section II.A.2 within 30 calendar days of the TO award.

In addition, in accordance with Task 3, JOA/MOU, the QIC shall accept imaged case files from the MACs. The methodology for information exchange shall be negotiated as part of the JOA development process and shall be in compliance with the Health Insurance Portability & Accountability Act of 1996 (HIPAA), the Privacy Act, the CMS ARS, and the National Institute of Standards and Technology (NIST) guidance.

Images Loaded into MAS/Verification Protocol:

The images loaded into MAS shall be verified as an exact duplicate of the hard copy/original documentation. In order to ensure compliance with this, the QIC shall develop and submit a protocol to ensure that the images loaded into MAS are exact duplicates of the original hard copy.

This protocol shall be submitted to CMS for review and approval within 30 days of the date of TO award.

Task 11: Activities Related to Limited Cases that the QIC Conducts an Extrapolation of the Claims at Issue

In accordance with USOW section I, the QIC shall conduct reconsiderations of initial Medicare claims determinations and service the related requests. In rare instances, due to the nature of the volume of claims at issue, the QIC shall, at a minimum:

• Consult with CMS regarding use of statistical extrapolation on any cases that have more than 250 claims;

• Upon approval from CMS, solicit approval from the appellant and if concurrence is provided, identify a statistically valid random sample (SVRS) extrapolation of the claims at issue (utilizing a statistician) and perform a limited claims review of the selected sample;

• Review all claims selected as part of the SVRS consistent with the CMS standards and guidelines (e.g., HCFAR 86-1, Internet Only Manual, Pub. 100-08, Chapter 3, §3.10) as outlined in the USOW and this SOW; and,

• Enter claims data in MAS for the claims reviewed as part of the SVRS (the QIC is not required to populate the MAS with all claims in the universe).

Under the Medicare fee-for-service appeals process, appellants who are dissatisfied with a QIC’s reconsideration decision may request a hearing before an ALJ. If an ALJ (and/or higher level of appeal) issues a decision that requires a recalculation of the extrapolated overpayment on a case that involved a SVRS identified and performed by the QIC, the QIC shall be responsible for performing any and all related re-extrapolations.

Accordingly, the QIC shall, at a minimum:

• Upon notification from the MAC regarding a request for re-extrapolation and/or receipt of the related ALJ decision (whichever is sooner), the QIC shall coordinate with the MAC or other CMS stakeholder, as necessary, to obtain all related information in order to appropriately and accurately recalculate the extrapolated overpayment;

• Expeditiously utilize a statistician to recalculate the extrapolated overpayment; and

• Provide the MAC with necessary documentation to accurately effectuate the claims related to this case in accordance with the ALJ’s (and/or further level of appeal) decision.

The QIC also may receive a small volume of re-extrapolation requests from ALJ (and/or higher level of appeal) decisions issued on cases that were subject to SVRS by the previous QIC for this jurisdiction. The QIC shall conduct the re-extrapolation and follow the requirements as detailed above.

Task 12: Destruction of Documents

The Part A West QIC shall destroy all paper case files once the case has been imaged and the image quality is verified. Upon approval of the Verification Protocol, as identified in Task 10, the QIC shall destroy all paper case files once the case has been imaged, the image quality is verified, the image is verified as stored in the MAS, and the image is held in accordance with CMS document retention policy. The QIC shall not be required to provide the AdQIC with hard copy case files for long-term storage.

Task 13: Participation in ALJ Hearings as a Participant or Witness

Effective March 20, 2017, several changes were made to the regulations that outline the activities related to QIC participation in ALJ hearings. Under the new regulations, CMS contractors are limited to 3 roles in an ALJ hearing: a Participant, a Party, or a Witness. These changes are outlined in 42 CFR §405.1010 and 42 CFR §405.1012. On November 22, 2017, CMS issued a modification to the AdQIC TO to develop a web-site that will assist with the coordination of CMS contractors’ participation in ALJ hearings. This task establishes the minimum requirements related to the A West QIC’s participation and related coordination activities.

Role of the Participant:

Under 42 CFR Part §405.1010(c) and (d)(1)(2)(3), the QIC’s participation as a participant (i.e., non-party) shall be limited to: submitting written testimony and/or position papers except as described below.

The regulations do not prohibit multiple CMS contractors and/or related entities from participating in the ALJ hearing as a participant. However, if no contractor or CMS invokes party status, then the first entity to submit their election to participate to the ALJ may participate in the oral hearing (limited to clarification of factual or policy issues, as requested by the ALJ).

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All other entities may elect to participate, but are precluded from the hearing and may only submit written testimony and/or position papers, as indicated above.

Oral participation in a hearing is limited solely to parties (including contractors who are made a secondary party to the hearing through the ‘leave’ process, as described below), and/or witnesses; except for situations as described above. Additional information regarding the roles of these entities is described below and in Optional Task 14.

Role of the Party:

Optional Task 14 provides information regarding the party status role and related activities.

Role of the Witness:

If a contractor is precluded from participating as a party in an ALJ hearing, the contractor may submit a request for ‘leave’ to the ALJ. The process in which this shall occur shall be defined at a later date. Further, the request for ‘leave’ process shall occur outside of the AdQIC portal. The ALJ shall make the determination as to whether the contractor is granted ‘leave.’ If this is approved, the contractor shall become a secondary party, or participant (e.g., in the event that no contractor or CMS invokes party status) to the hearing. The secondary party or participant (e.g., only for the situation described above) shall have the same rights as the primary party or participant.

The QIC shall track and report on the volume of ‘leave’ requests, volume approved, and volume denied. See Optional Task 14 for additional information regarding the role of a party.

If the ALJ declines a contractor’s request for ‘leave’ in a particular hearing, the contractor may either request to participate as a participant or be called as a ‘witness’ by CMS or another CMS contractor that is a party to the hearing. A determination regarding the need for a ‘witness’ by the participating party shall be determined by the party and communicated to the A West QIC prior to the hearing. The A West QIC shall participate as a ‘witness’ in any case in which another CMS contractor and/or CMS has requested their support in a hearing. The A West QIC shall notify the party and the CMS COR in rare instances in which the A West QIC is unable to support the party as a ‘witness.’ The A West QIC shall also track and report on the number of ALJ cases in which the QIC accepted or declined the request to be called as a witness.

This process and the related roles and responsibilities shall be further defined and outlined in the respective JOAs. As a ‘witness,’ the A West QIC shall be tasked with supporting the party by responding to policy or factual issues related to a particular case through direct examination and is subject to cross examination by the opposing party.

NOTE: Contractors who are interested in acting as a witness may indicate their interest via the AdQIC Portal. CMS contractors may indicate interest in participating as witness without first making a request for ‘leave’ with an ALJ. Additionally, in accordance with 42 CFR §405.1020, witness designations/elections shall be made during the coordination of interest/role selection process, as described below, and shall be included in the response to a given Notice of Hearing (NOH). The contractor who is made the party to hearing will be notified via email as to those entities who opted to be a participant and/or witness.

Election of Participation Prior to Receipt of a Formal Notice of Hearing (NOH):

The regulation also allows CMS contractors the opportunity to elect to participate as a participant before issuance and/or receipt of the formal NOH. See section 42 CFR §4015.1010(b)(1) for additional information. CMS is currently working with the OMHA to further develop this process. Additional guidance regarding this activity shall be provided at a later date. CMS notes that in accordance with the regulation, a position paper or written testimony must be submitted within 14 calendar days of an election to participate, if no hearing has been scheduled, or no later than 5 calendar days prior to the hearing if a hearing is scheduled. Further, there is a risk that the case may be later resolved by the ALJ, or an Attorney Adjudicator within the OMHA, without a hearing. If the hearing is later scheduled, the QIC will receive the formal NOH and shall follow the guidelines below.

Required Activities Following Receipt of the Formal NOH:

As the AdQIC is tasked with coordinating contractor interest in participation among the related CMS contractors and/or CMS, all NOHs will be sent directly to the AdQIC from the OMHA.

The AdQIC, within 2 calendar days of receipt of the formal NOH from OMHA, shall send an alert, via e-mail, to all applicable CMS contractors notifying them that a hearing has been scheduled. For NOHs received after standard business hours (e.g., 4:30 p.m., ET) and/or during weekends or business Holidays, as defined by the respective entity, the AdQIC portal is programmed to calculate the response time beginning with the next applicable business day [e.g., if the AdQIC receives the formal NOH on a Friday at 4:30 pm, the 2 calendar day timeframe begins on Monday (with Monday being day 0)].

Upon receipt of the formal NOH e-mail alert, the A West QIC shall log in to the AdQIC web-site, http://participation.q2a.com, to access the NOH information. The A West QIC shall make their election, via the AdQIC web-site, within 5 calendar days of the formal NOH e-mail sent date, if day 5 falls on a weekend or holiday, the deadline will not be pushed to the next business day. To make an election, the QIC must sign-in into the AdQIC’s website (see above), and a dashboard will be available listing all appeals for the QIC that they may choose to participate in.

The QIC will also be able to search for appeals based on the information provided in the notification email.

The A West QIC shall then select the applicable NOH and complete/submit the CMS Contractor Participation Form indicating whether they would like to participate as a party, participant, or witness, and/or if they would like to call a witness if made a party to the hearing. Note: the QIC will not be able to view the actual NOH document on the site. Additionally, the web-site/dashboard will allow the QIC to view all scheduled hearings for which they received a NOH.

NOTE: CMS contractors that fail to sign-in to the AdQIC system and make their respective participation role selections, in the required timeframe, may be precluded from the prioritization process as noted below.

Additionally, in the event that OMHA issues an amended NOH, the amended NOH email will be sent from OMHA directly to the AdQIC. The AdQIC shall alert all applicable CMS contractors of the amended NOH within 2 calendar days of receipt of the amended NOH

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