J-01A MAC Shared System BaseNonbase.doc

CMS-RFP-2010-0004

Attachment J-01A

CMS-RFP-2010-0004

Attachment J-01A

MAC Shared System Base and Non-Base Functions

Data Center security ID and password that controls access into the data center, access into the CICS regions, access to CICS transactions, and read/write access to files.

Data Center security Machine-ID and non-expiring password that controls access into the data center for functions such as IVR, NGD, Sequential Terminals and FEPI.

Tele-communications

Works with CMS-approved contractors as necessary to establish batch and interactive connectivity between the data centers.

File Transfers

The EDC creates and maintains the jobs necessary to transmit CMS-approved files from the EDC to any other location.

The EDC receives files transmitted from CMS approved contractors.

VMS accepts NCPDP transmission format to be translated and processed. This also includes NCPDP responses. Although this is a current process as of June 2009, it will be replaced with a feed from CEDI for NCPDP files similar to X12 files by December 2009.

VMS transfers NCPDP claims in their flat file format that are sent to the wrong processing region (misdirected claims). CEDI performs the misdirected claims process for claims received in the X12 format. By December 2009, CEDI will perform misdirected claim routing for claims received in either X12 or NCPDP formats.

The EDC creates and maintains the jobs necessary to transmit CMS approved files from the EDC to any other location.

Direct Data Entry (DDE) application for provider on-line inquiry of claims information (VPIQ.PINQ).

Automated Development System (ADS), including a base letter file selected from an existing user.

Creation and execution of the jobs to transmit the base print output to the contractor local data center.

CMS Maintenance (VDME)

On-line claims entry and work scheduler (VMON/APEX)

Weekly QA sampling

Letter-writing application, including a base letter file selected from an existing shared system user (ALGS).

Creation and execution of the jobs to extract the contractor-specific fee schedule data.

Standard provider profile build logic

Automated pricing of claims

Express Adjustments

MSP automated payment calculation

Receipt and installation of ECRS software.

· Workload and Performance reports;

· Appeals;

· Medical Review Workload;

· Medical Review Savings;

· PIMR;

· MSP Savings;

· CFO;

CEDI performs claims receipt, control and balancing for inbound claims from providers and the delivery to the EDC for processing. VMS provides reports to track processed claims.

Creation and execution of the jobs to transmit the PIMR data to CMS’ PIMR contractor.

Telecommunications mechanism between the EDC and the NSC.

Retrieval of the Daily Export Extract file from the NSC.

Creation and execution of bank-specific interfaces for Issues file (optional, with CMS approval).

Creation and execution of the jobs to transmit the issues file to the bank or contractor data center.

Receipt of the Clears file from the bank (optional).

Creation and execution of bank-specific interfaces for Clears file (optional, with CMS approval).

Stale date processing

Mailroom-ready output document files, suitable for printing on IBM equipment, that have:

· Basic AFP mixed mode print file;

· Parameters to control additional mail finishing marks;

· OMR coding or 3 of 9 barcodes for outgoing financial documents;

· Separate checks, MSNs, and remittance with AFP mixed mode formatted print streams;

· English language printed output for all documents, and Spanish language for the beneficiary Medicare Summary Notice (MSN);

· Base Presort processing.

Creation and execution of the jobs to transmit the base print output to the contractor’s print site (if routing is not done via the JCL).

— OR —

Produce image file that could be used to produce another format.

Creation and execution of the jobs to transmit the image file to the contractor’s print site (if routing is not done via the JCL).

Cash receipts processing

Accounts receivable processing

Accounts payable processing

Creation and execution of the jobs to transmit the ACH records to the bank or the contractor data center.

Creation of electronic claim status response transactions on one of the CMS-mandated flat file formats.

Creation and execution of the jobs to transmit the data to the contractor data center.

Creation of crossover data for the COBC in the mandated flat file format.

Support of telecommunications with trading partners/COBC.

Creation and execution of the jobs to transmit the crossover data to the COBC.

Automated history search capability to interface with ARGUS.

Sampling capability in support of focused medical review (online history plus 4 years of purged history).

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