QIC_RFI_2026.pdf

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REQUEST FOR INFORMATION

Qualified Independent Contractors (QIC) Request for Information

Agency/Office

Department of Health and Human Services (HHS), Centers for Medicare & Medicaid Services (CMS), Center for Medicare (CM), Medicare Enrollment and Appeals Group (MEAG)

Project Title Qualified Independent Contractors (QIC) On-Ramp

Classification Code R – Professional, administrative, and management support services

Primary NAICS Code 541611 - Administrative Management and General Management Consulting Services [Small Business Standard is $24.5M]

PSC Code R Category - 499 Response Date 11 AM Eastern Time, Thursday, November 5, 2026

1. Purpose The Centers for Medicare & Medicaid Services (CMS) Office of Acquisition and Grants Management (OAGM), on behalf of Medicare Enrollment and Appeals Group (MEAG), is conducting market research to support planning for the potential on-ramp of vendors to the existing Qualified Independent Contractor (QIC) Indefinite-Delivery/Indefinite-Quantity (IDIQ) contract. Specifically, CMS requests information from potential vendors regarding their capability to successfully perform some or all the work under the QIC IDIQ and requests that respondents describe the relevant experience demonstrating their ability to successfully perform the applicable QIC Line(s) of Business. CMS also seeks industry feedback regarding potential interest in an alternative task order structure for the Medicare Part C Line of Business, including whether dividing the current Part C Line of Business into multiple task orders would affect organizations' interest or ability to compete for Part C work.

The QIC IDIQ contract structure is based on an IDIQ Umbrella Statement of Work (USOW) and currently consists of eight separate Statements of Work (SOWs) covering Original Medicare (OM) Parts A, B, and Durable Medical Equipment (DME), Medicare Part C, Medicare Part D, and the Administrative Qualified Independent Contractor (AdQIC). Under the current contract structure, OM is performed through five separate task orders: Part A East, Part A West, Part B North, Part B South, and DME. Operationally, the Part A East and West task orders perform the same business functions but serve different geographic jurisdictions. Likewise, the Part B North and South task orders perform the same business functions but serve different geographic jurisdictions. The jurisdictions identify the geographic areas covered under each task order. Currently, the Part C and Part D QICs are national contracts and are not divided by geographic jurisdictions.

CMS/OAGM, consistent with the requirements of Federal Acquisition Regulation (FAR) Subpart 9.5, developed and maintains Conflict of Interest (COI) requirements applicable to the QIC IDIQ. The scope of work requires consideration of CMS' COI requirements and the specific restrictions applicable to the QIC program (see Attachment 10) at the task order level. As described in Attachment 10, a QIC must be an independent entity and cannot perform, or have influence over, initial determinations that may later be subject to review under the respective QIC contract. Additionally, an organization that holds the AdQIC contract may not hold an OM QIC contract or conduct reconsiderations under the OM or Parts C and D QIC programs as a prime contractor or subcontractor, as outlined in Attachment 10. Accordingly, CMS seeks information regarding:

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A. An organization's ability to be evaluated for, and added to, the QIC IDIQ in a conflict-free manner; and B. An organization's ability to compete for future QIC Letter Requests for Proposals (LRFPs) while complying with the applicable COI requirements.

Objectives

CMS seeks to:

• Identify additional potential vendors to serve as QICs in a conflict-free manner.

• Identify possible programmatic, operational, contractual, or other impediments to vendor participation.

• Determine potential vendor willingness to participate in future QIC LRFPs.

• Assess the marketplace's capability to successfully perform some or all the work under the QIC

IDIQ.

• Promote operational efficiencies and high-quality performance.

• Further best value efforts.

To facilitate meaningful market research and an exchange of information between CMS and industry, domain-focused questions have been developed to obtain detailed feedback regarding critical programmatic functions, respondents' organizational capabilities demonstrated through relevant experience, and their ability to successfully perform core QIC functions. Respondents should provide sufficient detail to demonstrate how their relevant experience supports the specific Line(s) of Business they seek to support.

Where applicable, respondents may describe experience from Medicare or other comparable healthcare or health insurance programs, provided they clearly explain how the experience demonstrates their organization's capability to successfully perform the identified QIC Line(s) of Business. Responses should provide sufficient detail to enable CMS to assess a respondent’s capability to successfully perform the identified QIC Line(s) of Business without requiring the Government to infer the relevance or applicability of the experience provided.

For response purposes, “All the Work” is defined as a respondent’s ability to successfully perform, in a conflict-free manner, the requirements of the QIC IDIQ Umbrella Statement of Work and the work described in all eight Task Order SOWs. Similarly, “Some of the Work” is defined as a respondent’s ability to successfully perform, in a conflict-free manner, the requirements of the QIC IDIQ Umbrella Statement of Work and the work described in one or more, but not all, of the eight Task Order SOWs.

THIS IS A REQUEST FOR INFORMATION (RFI) ONLY. This RFI is issued solely for CMS' information and acquisition planning purposes. This RFI does not constitute a Request for Proposal (RFP) or represent a commitment by the Government to issue an RFP or otherwise procure any supplies or services. CMS is not soliciting proposals at this time. Respondents are advised that the U.S. Government will not reimburse any costs incurred in preparing or submitting a response to this RFI. All costs associated with responding to this RFI are solely the responsibility of the respondent. A response to this RFI is not required and will not preclude participation in any future procurement. Interested organizations are responsible for monitoring SAM.gov (or any successor Government Point of Entry) for future notices related to this requirement.

Information provided in response to this RFI is subject to change and is not binding on the Government.

HHS, CMS, CM, MEAG, and OAGM have not made a commitment to procure any of the items discussed, and release of this RFI does not authorize the Government to reimburse any costs associated with responding to this notice. All submissions become Government property and will not be returned.

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2. Responding to This Request Respondents are requested to submit a response to this RFI in Microsoft Word format consisting of the following information:

1. General Vendor Information, including:

• Organization Name

• Mailing address

• Name, phone number and e-mail address of designated point of contact

• Business type (large business, small business, small, disadvantaged business, 8(a)-certified small, disadvantaged business, HUBZone small business, woman-owned small business, very small business, veteran-owned small business, service-disabled veteran-owned small business).

• QIC Line(s) of Business for Which the Organization Seeks Consideration (select all that apply):

□ Original Medicare Part A

□ Original Medicare Part B

□ Original Medicare DME

□ AdQIC

□ Medicare Part C

□ Medicare Part D

□ All of the Above

• Brief Relevant Experience Summary: identify up to three contracts or programs that best demonstrate your organization's experience relevant to the QIC work described in this RFI. For each, identify the customer or program, your organization's role (e.g., prime contractor or subcontractor), and the general scope of work performed.

2. Responses to the technical questions:

• Respondents must provide responses to the technical questions included in the QIC RFI Technical

Questions workbook provided as an attachment to this notice.

• Responses should be organized by section and question number and should clearly identify the question being addressed.

• Respondents must address the questions applicable to the QIC Line(s) of Business for which they seek consideration.

• There is no page limit for responses to this RFI. Respondents are encouraged to provide clear, concise, and sufficiently detailed responses that address the information requested.

If your organization performs the same or similar services outlined in this RFI under a North American Industry Classification System (NAICS) code other than the Primary NAICS code listed above (541611), please provide this information as well as the business type under the NAICS code(s), and contractual vehicle for which it applies.

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Note: The applicable COI requirements for the OM, Part C, and Part D QICs are set out in Attachment 10 and are the same across the OM QIC and Part C and D QIC jurisdictions, respectively, identified in the respective SOWs. However, responsibilities and functions may differ among the respective QIC SOWs and Line(s) of Business. Additionally, each SOW defines the applicable jurisdiction and scope (e.g., Medicare claim type, states within the respective jurisdiction, etc.). Therefore, potential COI concerns may vary by QIC jurisdiction as defined in the respective SOW and related Task Order Solicitation. Accordingly, respondents should review the USOW, applicable Task Order SOW(s), and Attachment 10 before preparing a response to ensure they understand the scope of work and any potential conflict-of-interest implications associated with the Lines of Business they seek to support.

The information gained from this RFI will be for CMS internal use and consideration. CMS does not intend to provide written responses to the questions or comments submitted in response to this RFI but will consider the comments and questions when finalizing procurement actions.

2.1 Size Status Information:

The primary NAICS code for this requirement is 541611, Administrative Management and General Management Consulting Services. "Small Business Concern" means a concern, including its affiliates that is independently owned and operated, not dominant in the field of operation in which it is bidding on Government contracts, and qualified as a small business under the criteria and size standards in 13 CFR part 121. The size standards for each NAICS and PSC code to be qualified as a small business can be found on the following site: https://www.sba.gov/counseling/get-started/#size-standards.

A small business concern for the purposes of work within NAICS code 541611 is generally defined as a business, including its affiliates, averaging no more than $24.5 million dollars in annual receipts.

To qualify, annual receipts of a concern that have been in business for three (3) or more complete fiscal years means the annual average gross revenue of the concern taken for the last three (3) fiscal years.

Annual receipts of a concern that has been in business for less than three (3) complete fiscal years means its total receipts for the period it has been in business, divided by the number of weeks including fractions of a week that it has been in business, and multiplied by 52. Potential vendors are cautioned, however, that this is a general description only. Additional standards and conditions apply. Please refer to Federal Acquisition Regulation FAR 19 for additional detailed information on Small Business Size Standards. The FAR is available at https://www.acquisition.gov/.

3. Background There is a five-level appeals process that affords providers, suppliers, beneficiaries, enrollees, and other parties an opportunity to appeal certain Medicare coverage, payment, and other determinations. While differences exist in the processes and terminology applicable to OM (Part A, Part B, and DME), Medicare Part C, and Medicare Part D appeals, the levels of appeal are generally consistent as described in the table below.

Appeal Level

Original Medicare (OM) Claim Appeals

Medicare Part C Appeals Medicare Part D Appeals

Level One

Redetermination by a Medicare Administrative Contractor (MAC): An independent review of an initial determination of an OM claim.

Reconsideration by Health Plan. Redetermination by Part D Plan sponsor.

Level Two

Reconsideration by a QIC:

Reconsideration by an Independent Review Entity (IRE) under the QIC IDIQ:

Reconsideration by an IRE under the QIC IDIQ:

https://www.sba.gov/counseling/get-started/#size-standards https://www.acquisition.gov/

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An independent, on-the record, review of an initial determination, including the redetermination or dismissal and all issues related to payment of the claim.

An independent review of a health plan’s adverse reconsideration, a health plan’s dismissal of an appellant reconsideration request, or an independent review when the health plan fails to meet the adjudicatory timeframes for reconsideration request.

An independent review of a sponsor’s adverse redetermination, dismissal of an appellant redetermination request or an independent review when the plan fails to meet the adjudicatory timeframes of an initial coverage determination or redetermination request.

Level Three

Hearing by an Administrative Law Judge (ALJ) or Attorney Adjudicator within the Office of Medicare Hearings and Appeals (OMHA) within the Department of Health and Human Services: Under OM provisions, if a party is dissatisfied with a QIC’s reconsideration or dismissal the party has the opportunity to request a hearing or review from OMHA. For OM claims, if the mandated adjudication period for the QIC to complete the reconsiderations has elapsed and the QIC is unable to complete the reconsideration by the deadline, a party has the opportunity to escalate an appeal to OMHA for a hearing.

Under Part C provisions, if any party to the reconsideration (except the Health Plan) is dissatisfied with the Independent Review Entity’s (IRE’s) reconsideration determination or dismissal, the party may request an ALJ hearing or an Attorney Adjudicator review.

Under Part D provisions, if the enrollee or enrollee’s representative is dissatisfied with IRE’s reconsideration or dismissal, the enrollee may request an ALJ hearing or an Attorney Adjudicator review.

For Calendar Year (CY) 2026, the Amount in Controversy (AIC) to appeal at the ALJ/OMHA level is $200.

Level Four

Review by the Medicare Appeals Council (Appeals Council) within the Departmental Appeals Board (DAB) in the Department of Health and Human Services: An on-the-record review of an ALJ or attorney adjudicator’s decision or dismissal order.

Level Five

Judicial review in Federal District Court: A judicial review of the Appeals Council’s decision by Federal District Court. The AIC to appeal at the Federal District Court for CY 2026, is $1,960.

3.1 Level 2 QIC Appeals Workload and Additional Information:

Information regarding Level 2 appeals workload activities, QIC covered regions, and general QIC program information for OM can be found at: https://www.cms.gov/Medicare/Appeals-and- Grievances/OrgMedFFSAppeals/ReconsiderationbyaQualifiedIndependentContractor and https://www.cms.gov/medicare/appeals-and-grievances/orgmedffsappeals/downloads/appeals-fact-sheets-2011-2018-v508-zipfile.zip.

Information regarding Medicare Part C and D Level 2 appeals workload activities and general Part C and D QIC program information can be found at: https://www.cms.gov/medicare/appeals-grievances/managed-care/review-part-c-independent-entitiy, https://www.cms.gov/medicare/appeals-grievances/prescription-drug/reconsiderations, and https://www.cms.gov/medicare/appeals-and-grievances/mmcag/downloads/parts-c-and-d-enrollee-grievances-organization-coverage-determinations-and-appeals-guidance.pdf.

https://www.cms.gov/Medicare/Appeals-and-Grievances/OrgMedFFSAppeals/ReconsiderationbyaQualifiedIndependentContractor https://www.cms.gov/Medicare/Appeals-and-Grievances/OrgMedFFSAppeals/ReconsiderationbyaQualifiedIndependentContractor https://www.cms.gov/medicare/appeals-and-grievances/orgmedffsappeals/downloads/appeals-fact-sheets-2011-2018-v508-zipfile.zip https://www.cms.gov/medicare/appeals-and-grievances/orgmedffsappeals/downloads/appeals-fact-sheets-2011-2018-v508-zipfile.zip https://www.cms.gov/medicare/appeals-grievances/managed-care/review-part-c-independent-entitiy https://www.cms.gov/medicare/appeals-grievances/managed-care/review-part-c-independent-entitiy https://www.cms.gov/medicare/appeals-grievances/prescription-drug/reconsiderations https://www.cms.gov/medicare/appeals-grievances/prescription-drug/reconsiderations https://www.cms.gov/medicare/appeals-and-grievances/mmcag/downloads/parts-c-and-d-enrollee-grievances-organization-coverage-determinations-and-appeals-guidance.pdf https://www.cms.gov/medicare/appeals-and-grievances/mmcag/downloads/parts-c-and-d-enrollee-grievances-organization-coverage-determinations-and-appeals-guidance.pdf https://www.cms.gov/medicare/appeals-and-grievances/mmcag/downloads/parts-c-and-d-enrollee-grievances-organization-coverage-determinations-and-appeals-guidance.pdf

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Respondents should consider the available workload information and current QIC task order structure when assessing their capability to perform the applicable QIC Line(s) of Business. For purposes of this RFI, respondents should assess their capability to perform OM work based on the existing Part A, Part B, and DME task order and jurisdictional structure described herein. CMS is not seeking recommendations through this RFI to modify the existing OM task order or jurisdictional structure.

Medicare Part A and Part B (OM)

• OM coverage and payment determinations.

• Determinations related to Medicare beneficiary eligibility and entitlement, Part B late enrollment, and income related monthly adjustment amounts (IRMAAs) that apply to Part B.

Key Provisions:

Section 1869 (https://www.ssa.gov/OP_Home/ssact/title18/1869.htm) of the Social Security Act;

42 USC 1395ff (https://www.law.cornell.edu/uscode/text/42/1395ff) 42 CFR Part 405, Subpart I: (https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-

B/part-405/subpart-I/subject-group-ECFR533a2e506b78025) CMS Guidance: (https://www.cms.gov/medicare/appeals-and-grievances/orgmedffsappeals) and

(https://www.cms.gov/Regulations-and- Guidance/Guidance/Manuals/Downloads/clm104c29pdf.pdf)

Quality Improvement Organization (QIO) Determinations

• Reviews certain determinations regarding Medicare services including: 1) A provider discharge of an individual from the provider of services, and 2) A provider termination of services when physician has made certain clinical certifications.

Sections 1155 (https://www.ssa.gov/OP_Home/ssact/title11/1155.htm) & Section 1154

(https://www.ssa.gov/OP_Home/ssact/title11/1154.htm) of the Social Security Act; 42 USC 1320c- 4 (https://www.law.cornell.edu/uscode/text/42/1320c-4); see also, Section 1869(c)(3)(C) (https://www.ssa.gov/OP_Home/ssact/title18/1869.htm)

Medicare Part C - Medicare Managed Care & Other Health Plan Appeals

• Appeals of organization determinations regarding benefits or medical care.

• Medicare Advantage Organization (MAO) determinations and reconsiderations of adverse determinations.

Key Provisions:

Section 1852(g) (https://www.ssa.gov/OP_Home/ssact/title18/1852.htm) of the Social Security

Act; 42 USC 1395w-22 (https://www.law.cornell.edu/uscode/text/42/1395w-22) 42 CFR Part 422, Subpart M (https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-

B/part-422/subpart-M?toc=1) CMS Guidance: (https://www.cms.gov/Medicare/Appeals-and-Grievances/MMCAG)

Other HMOs & Competitive Health Plan Organization Determinations: Section 1876 (https://www.ssa.gov/OP_Home/ssact/title18/1876.htm) of the Social Security Act; 42 USC 1395mm (https://www.law.cornell.edu/uscode/text/42/1395mm)

Medicare Part D

• Plan sponsor prescription drug coverage determinations, redeterminations, at-risk determinations, dismissals, income related monthly adjustment amounts (IRMAAs) that apply to Part D premiums (determined by the Social Security Administration).

https://www.ssa.gov/OP_Home/ssact/title18/1869.htm https://www.law.cornell.edu/uscode/text/42/1395ff https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-405/subpart-I/subject-group-ECFR533a2e506b78025 https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-405/subpart-I/subject-group-ECFR533a2e506b78025 https://www.cms.gov/medicare/appeals-and-grievances/orgmedffsappeals https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c29pdf.pdf https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c29pdf.pdf https://www.ssa.gov/OP_Home/ssact/title11/1155.htm https://www.ssa.gov/OP_Home/ssact/title11/1154.htm https://www.law.cornell.edu/uscode/text/42/1320c-4 https://www.ssa.gov/OP_Home/ssact/title18/1869.htm https://www.ssa.gov/OP_Home/ssact/title18/1852.htm https://www.law.cornell.edu/uscode/text/42/1395w-22 https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-422/subpart-M?toc=1 https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-422/subpart-M?toc=1 https://www.cms.gov/Medicare/Appeals-and-Grievances/MMCAG https://www.ssa.gov/OP_Home/ssact/title18/1876.htm https://www.law.cornell.edu/uscode/text/42/1395mm

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• Reconsiderations of adverse determinations related to prior creditable prescription drug coverage/imposition of a Late Enrollment Penalty (LEP).

Section 1860D-4 (https://www.ssa.gov/OP_Home/ssact/title18/1860D-04.htm) of the Social

Security Act; 42 USC 1395w-104 (https://www.law.cornell.edu/uscode/text/42/1395w-104) 42 CFR Part 423, Subparts B (eCFR :: 42 CFR Part 423 Subpart B -- Eligibility and Enrollment), M

(https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-423/subpart-M) and U (https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-423/subpart-U?toc=1,)

CMS Guidance: (https://www.cms.gov/medicare/appeals-and-grievances/medprescriptdrugapplgriev)

Prescription Drug Benefit Manual Chapters:

https://www.cms.gov/medicare/coverage/prescription-drug-coverage-contracting/prescription-drug-benefit-manual.)

3.2 Programmatic and Operational Information:

The current COI policy requires submission of a plan during a procurement (Letter Request for Proposal) as well as updates to the plan if an organizational or similar change occurs. Current QIC contractors only certify COI requirements if they are responding to an LRFP or if something changes at a corporate level.

Attachment 10 identifies the current COI requirements and known restrictions.

4. Information Exchange (Questions for Respondents) In responding to this RFI, respondents should address the technical questions provided in the attached workbook and demonstrate their capability to perform some or all the work under the QIC IDIQ.

Responses should address the applicable QIC Line(s) of Business selected by the respondent and provide sufficient detail regarding the business functions performed, governing authorities applied, professional workforce utilized, and relevant experience supporting the respondent's capability to successfully perform the applicable QIC work. Responses should clearly demonstrate the respondent's knowledge of, experience with, and ability to perform the requested QIC functions.

Where applicable, respondents may describe experience from Medicare or other comparable healthcare or health insurance programs, provided they clearly explain how the experience demonstrates their organization's capability to successfully perform the identified QIC Line(s) of Business. Responses should provide sufficient detail to enable CMS to assess a respondent's capability to successfully perform the identified QIC Line(s) of Business without requiring the Government to infer the relevance or applicability of the experience provided.

Respondents seeking to perform "All the Work" should address all applicable Lines of Business.

Respondents seeking to perform "Some of the Work" should respond only to the Line(s) of Business for which they seek consideration.

4.1 Programmatic and Operational Questions:

4.1.1) Based on the information provided in this RFI, describe your organization’s overall capability to perform some or all the work under the QIC IDIQ. Please explain.

4.1.1a) Identify the specific QIC Line(s) of Business your organization is capable of supporting and provide a summary of the relevant and direct experience supporting each identified Line of Business.

4.1.2) What barriers other than those related to Conflict of Interest, if any, does your organization believe may affect participation in the QIC IDIQ? Please explain.

https://www.ssa.gov/OP_Home/ssact/title18/1860D-04.htm https://www.law.cornell.edu/uscode/text/42/1395w-104 https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-423/subpart-B?toc=1 https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-423/subpart-M https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-423/subpart-U?toc=1 https://www.cms.gov/medicare/appeals-and-grievances/medprescriptdrugapplgriev https://www.cms.gov/medicare/appeals-and-grievances/medprescriptdrugapplgriev

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4.1.3) Has your organization previously considered participating in the QIC IDIQ? If yes, did your organization express that interest to CMS? If your organization considered participating but did not pursue the opportunity, please explain why and describe any factors that influenced that decision.

4.1.4) In your opinion, what capabilities, operational requirements, or other factors present the greatest challenge to developing and maintaining a successful QIC operation? Additionally, what barriers, if any, may deter organizations from participating in the QIC IDIQ? Please explain.

4.1.4a) CMS is seeking industry feedback regarding potential approaches to support the growing needs of the Medicare Part C Line of Business. One option under consideration would divide the current national Part C Line of Business into two task orders that perform the same business functions but serve different geographic areas. Please describe how this option would affect your organization's interest or ability to participate in the QIC IDIQ and explain the reasoning behind your response.

4.1.5) Please describe your organization's experience, if any, related to Medicare Part A, B, and/or DME claims.

4.1.6) Please describe your organization's experience, if any, reviewing Medicare claims for compliance with Medicare Part A, B, and/or DME coverage and policy requirements.

4.1.7) Please describe your organization’s experience, if any, related to Medicare Part C organization determinations and appeals.

4.1.8) Please describe your organization’s experience, if any, reviewing Medicare Part C organization determinations and appeals for compliance with Medicare coverage criteria and policy requirements.

4.1.9) Please describe your organization's experience, if any, related to the Medicare Part D Prescription Drug Benefit.

4.1.10) Please describe your organization's experience, if any, reviewing Medicare Part D prescription drug benefits for compliance with Medicare Part D coverage criteria and policy requirements.

4.1.11) Please describe any additional thoughts, concerns, or recommendations your organization would like CMS to consider regarding participation in the QIC IDIQ. Please explain.

4.2 Conflict of Interest (COI) Focused Questions:

4.2.1) Based on your understanding of the COI requirements outlined in Attachment 10, do you have any existing, potential, or perceived conflicts of interest that could affect your organization's ability to perform some or all the work under the QIC IDIQ? If yes, please describe the conflict(s) and explain whether and how they could be mitigated consistent with the existing QIC COI requirements outlined in Attachment 10.

4.2.1a) Based on the requirements of the QIC IDIQ and your organization's current work, are there arrangements under which your organization could perform some, but not all, of the QIC Lines of Business in a conflict-free manner? Please explain.

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4.2.2) Does your organization have any other Medicare program contracts or functions that are similar or related to functions performed by the QIC? Specifically, does your organization conduct medical review, coverage review, claims review, or other same/similar review activities related to Medicare? If so, in what capacity?

4.2.3) How does your organization currently identify and address COI-related issues or concerns in its existing work? Please explain.

4.2.4) What procedures does your organization have in place today to address COI requirements like those incorporated in the QIC IDIQ? Please explain. Also, is your organization able to submit a potential COI mitigation plan? If yes, please explain the proposed approach considering the existing COI policies for the QIC IDIQ as outlined in Attachment 10. If not, please explain why your organization is unable to submit a potential COI mitigation plan.

4.2.5) What procedures does your organization have in place to identify, monitor, and disclose personal conflicts of interest, including financial interests or relationships, involving managers or key personnel, governing body members, organizational principals, or other individuals whose interests could affect performance of the QIC contract? Please explain.

4.2.6) Describe any additional thoughts or concerns your organization may have related to the QIC COI requirements. Please explain.

4.3 Relevant Experience and Capability:

The purpose of this section is for respondents to demonstrate, through relevant and direct experience, their organizational capability to successfully perform the QIC Line(s) of Business identified in Section 4.1.1a. For each applicable capability described in this section, respondents should describe the work performed, explain how the work was performed, identify their organization's role and responsibilities, and explain why the experience is relevant to the applicable QIC business function(s) and Line(s) of Business.

Where applicable, respondents may describe experience from Medicare or other comparable healthcare or health insurance programs, provided they clearly explain how the experience demonstrates their organization's capability to successfully perform the identified QIC Line(s) of Business. Responses should provide sufficient detail to enable CMS to assess the respondent's capability to successfully perform the identified QIC Line(s) of Business without requiring the Government to infer the relevance or applicability of the experience provided.

Operational Infrastructure and Administrative Support:

4.3.1) Describe your organization's relevant and direct experience developing, operating, and maintaining Section 508-compliant public-facing websites, secure web portals, or similar web-based capabilities in support of Federal healthcare programs or other similar programs. Describe the work performed, your organization's role and responsibilities, and explain how the experience demonstrates your organization's capability to successfully perform the QIC Line(s) of Business identified in Section 4.1.1a.

4.3.2) Describe your organization's relevant and direct experience performing administrative processing of healthcare claims data, appeal case files, medical benefits-related case files and information, or other comparable case-related data, including document imaging, document management, scanning, uploading, downloading, and managing information within case management or other comparable systems. Describe the work performed, your organization's role

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4.3.3) Describe your organization's relevant and direct experience providing administrative services necessary to support Medicare appeals operations or other similar appeals programs, including data analysis, reporting, and operational support activities. Describe the work performed, your organization's role and responsibilities, and explain how the experience demonstrates your organization's capability to successfully perform the QIC Line(s) of Business identified in Section 4.1.1a.

4.3.4) Describe your organization's relevant and direct experience performing case management and documentation activities, including electronic case management, document imaging, and the use of the Medicare Appeals System (MAS) or other comparable case management systems.

Describe the work performed, your organization's role and responsibilities, and explain how the experience demonstrates your organization's capability to successfully perform the QIC Line(s) of Business identified in Section 4.1.1a.

4.3.5) Describe your organization's relevant and direct experience collecting, maintaining, and transmitting information regarding the receipt, workflow, and disposition of appeals or other similar activities using the Medicare Appeals System (MAS) or other comparable systems of record.

Describe the work performed, your organization's role and responsibilities, and explain how the experience demonstrates your organization's capability to successfully perform the QIC Line(s) of Business identified in Section 4.1.1a.

4.3.6) Describe your organization's relevant and direct experience developing, obtaining, and managing medical records or other documentation necessary to support the analysis, review, and adjudication of appeals or other similar activities. Describe the work performed, your organization's role and responsibilities, and explain how the experience demonstrates your organization's capability to successfully perform the QIC Line(s) of Business identified in Section 4.1.1a.

4.3.7) Describe your organization's relevant and direct experience identifying, implementing, and sustaining process improvements within Medicare programs or other similar programs at the project, program, or enterprise level. Describe the work performed, your organization's role and responsibilities, and explain how the experience demonstrates your organization's capability to successfully perform the QIC Line(s) of Business identified in Section 4.1.1a.

Reconsideration and Appeals Operations:

4.3.8) Describe your organization's relevant and direct experience processing standard and expedited Medicare reconsiderations or other comparable health insurance appeals involving medical necessity, coverage, payment, or other adjudicative determinations. Describe the work performed, your organization's role and responsibilities, and explain how the experience demonstrates your organization's capability to successfully perform the QIC Line(s) of Business identified in Section 4.1.1a.

4.3.9) Describe your organization's relevant and direct experience applying Medicare statutes, regulations, coverage and payment policies, National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), CMS manuals, or other governing authorities to support claims review, medical review, reconsiderations, appeals, or other similar adjudicative activities. Describe the work performed, your organization's role and responsibilities, and explain how the experience

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4.3.10) Describe your organization's relevant and direct experience monitoring compliance with the timely effectuation of appeal decisions, including decisions that reverse, in whole or in part, an initial coverage or payment determination, or performing other similar activities. Describe the work performed, your organization's role and responsibilities, and explain how the experience demonstrates your organization's capability to successfully perform the QIC Line(s) of Business identified in Section 4.1.1a.

4.3.11) Describe your organization's relevant and direct experience conducting statistical extrapolation of Medicare appeals claims, reviewing appeals of Medicare claims previously subject to statistical extrapolation, or performing other similar statistical sampling and analysis activities.

Describe the work performed, your organization's role and responsibilities, and explain how the experience demonstrates your organization's capability to successfully perform the QIC Line(s) of Business identified in Section 4.1.1a.

Clinical, Technical, and Professional Capability:

4.3.12) Describe your organization's relevant and direct experience providing access to physicians with experience and knowledge of Medicare coverage and payment policies necessary to support medical review activities related to Original Medicare, Medicare Part C, or Medicare Part D. Identify the applicable Medicare program(s), describe the physician expertise available to your organization, the work performed, your organization's role and responsibilities, and explain how the experience demonstrates your organization's capability to successfully perform the QIC Line(s) of Business identified in Section 4.1.1a.

4.3.13) Describe your organization's relevant and direct experience establishing, managing, and sustaining the professional workforce necessary to perform claims review, medical review, reconsiderations, appeals, or other similar adjudicative activities. Describe the key professional disciplines and functional roles supported, the work performed, your organization's role and responsibilities, and the approaches used to recruit, develop, train, manage, and retain this workforce. Explain how the experience demonstrates your organization's capability to successfully perform the QIC Line(s) of Business identified in Section 4.1.1a.

4.3.14) Describe your organization's relevant and direct experience performing or supporting claims auditing, quality assurance, or quality review activities as a prime contractor or subcontractor in support of Medicare or other similar healthcare programs, including evaluating the accuracy, consistency, and quality of claims, appeals, medical review activities, or other adjudicative determinations. Describe the work performed, your organization's role and responsibilities, and explain how the experience demonstrates your organization's capability to successfully perform the QIC Line(s) of Business identified in Section 4.1.1a.

4.3.15) Describe your organization's relevant and direct experience performing Medicare auditing or medical review activities, including experience acting as or supporting a Medicare Administrative Contractor (MAC), Recovery Audit Contractor (RAC), Unified Program Integrity Contractor (UPIC), Supplemental Medical Review Contractor (SMRC), or other similar Medicare program integrity or claims review function. Describe the work performed, your organization's role and responsibilities, and explain how the experience demonstrates your organization's capability to successfully perform the QIC Line(s) of Business identified in Section 4.1.1a.

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Appeals Coordination and Program Integrity:

4.3.16) Describe your organization's relevant and direct experience participating in Administrative Law Judge (ALJ) hearings or other similar administrative appeal proceedings as a party, participant, witness, or in another authorized capacity. Describe the work performed, your organization's role and responsibilities, and explain how the experience demonstrates your organization's capability to successfully perform the QIC Line(s) of Business identified in Section 4.1.1a. If applicable, describe your experience under 42 CFR §§ 405.1010-405.1012 or comparable authorities.

4.3.17) Describe your organization's relevant and direct experience coordinating with CMS, Medicare contractors, health plans, and other organizations to support Medicare appeals activities, including but not limited to, the Administrative QIC (AdQIC), other QICs, Medicare Administrative Contractors (MACs), Quality Improvement Organizations (QIOs), Medicare Secondary Payer (MSP) contractors, Medicare Advantage Organizations (MAOs), Part D plan sponsors, the Office of Medicare Hearings and Appeals (OMHA), the Medicare Appeals Council within the Departmental Appeals Board (Appeals Council), the Department of Justice (DOJ), the Office of Inspector General (OIG), the Government Accountability Office (GAO), or other similar organizations. Describe the work performed, your organization's role and responsibilities, and explain how the experience demonstrates your organization's capability to successfully perform the QIC Line(s) of Business identified in Section 4.1.1a.

4.3.18) Describe your organization's relevant and direct experience identifying and referring quality-of-care concerns or suspected fraud, waste, or abuse concerns in accordance with established procedures. Describe the work performed, your organization's role and responsibilities, and explain how the experience demonstrates your organization's capability to successfully perform the QIC Line(s) of Business identified in Section 4.1.1a.