J-01B SoW appendices.doc

CMS-RFP-2010-0004

Attachment J-01B Statement of Work Appendices

APPENDICES

2A.

KEY DEFINITIONS

12B.

ACRONYM LIST

18C.

REQUIREMENTS FOR THE ONLINE CLAIMS STATUS CAPABILITY

19D.

DATA RELEASE POLICIES AND PROCEDURES

28E.

FREEDOM OF INFORMATION GROUP POLICY AND PROCEDURE GUIDE

A.

KEY DEFINITIONS

Definitions critical to understanding this Statement of Work are provided in this section. Additional definitions are available on http://www.cms.hhs.gov. In this statement of work:

“Acceptable Quality Level” (AQL) means the minimum level of (expected) performance that is acceptable. Failure to achieve this level of performance renders the service being provided by the contractor unacceptable.

“Activity” means a unit or description of work usually done by one or more persons belonging to the same office, branch or other small group.

“Adjudicate” means processing a claim to a finalized status. Adjudicate also means the process of rendering a decision on a pending appeal. Sometimes the term is used to refer to making a decision on an issue/question that does not have administrative appeal rights.

“Administrative Requirement” means a general requirement related to the overall management and administration of the entity’s contract with CMS (e.g., internal controls, systems security) and can be driven by Agency requirement, contractual clause, contractual amendment, or legislation.

“Administrative Qualified Independent Contractor” (AdQic) means a contractor that supports a QIC with training and data analysis.

“American National Standards Institute” (ANSI) is an organization that accredits various standards-setting committees, and monitors their compliance with the open rule-making process that they must follow to qualify for ANSI accreditation. HIPAA prescribes that the standards mandated under it be developed by ANSI-accredited bodies whenever practical.

“Appellant” means the beneficiary, assignee or other person or entity that has filed an appeal concerning a particular initial determination.

“Assignee” means a provider, physician or other supplier that furnishes items or services to a beneficiary and has accepted a valid assignment of a claim or an appeal executed by the beneficiary.

“Beneficiary Contact Center” (BCC) means a customer service center handling telephone and written inquiries from Medicare beneficiaries and/or other authorized persons.

“Benefit Account Balance” means any daily collected balance (positive or negative) that may exist in the benefits account after all items presented for payment have been cleared. The earnings or loss resulting from any such balances will be included in the quarterly computation to adjust the Federal Health Insurance (FHI) time account.

“Bill” - see “Claim.”

“Billing Error” means an error that prevents a claim or bill from being properly adjudicated.

“Certificate of Medical Necessity” (CMN) means a form or other document containing information required by the carrier to be submitted to show that an item is reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. CMNs contain questions that reflect the local medical review policy for the item being billed. CMNs also require other types of administrative information that is useful for the carrier or other entity to ensure that the item billed was reasonable and necessary.

“Change Request” (CR) means a proposed or required change to CMS policy or procedures.

“Claim” means a transaction submitted by a provider or beneficiary that meets all the requirements in 42 CFR 424.30-424.44. (See also “recovery claim.”) “Claims-related transaction” means a transaction other than a claim, which the contractor must process. This includes but is not limited to HIPAA related transactions and Method Selection forms for home dialysis.

“Clean claim” means a claim that does not contain a defect requiring the MAC to investigate or develop prior to adjudication. Clean claims must be filed within the timely filing period (see the Act 1842(c)(2)(B)).

“Common Working File (CWF)” means the Medicare pre-payment validation and authorization system that forms the cornerstone for Medicare transactions processing. It is the single data source that verifies beneficiary eligibility and provides prepayment review and approval of claims.

“Complaint”. See either “Fraud and Abuse Complaints” or “Provider Complaint.”

“Compliance Error Rate” means a rate that is based on how the claims looked when they first arrived at the contractor - before the contractor applied any edits or conducted any reviews. The provider compliance rate is a good indicator of how well the contractor is educating the provider community because it measures how well providers prepared claims for submission. This error rate is based on dollars.

“Complex Inquiries” means those inquiries (telephone or written) from Medicare beneficiaries that cannot be resolved by the Beneficiary Contact Center because further research is required or no desktop scripting exists addressing the issue.

“Comprehensive Error Rate Testing” (CERT) means a CMS program to produce national, contractor specific, and service-specific paid claim error rates.

“Closeout Period” means the time between the award of a jurisdiction to a new MAC and the end of the incumbent contractor’s (FI, carrier, DMERC, or MAC) contract.

“Critical Edits” means edits that search for data in a submission to determine whether the submission has met the requirements to be considered a claim, in accordance with 42 CFR §424.30 - §424.45.

“Cutover” means the actual point at which the outgoing contractor ceases Medicare operations and the new contractor begins to perform its Medicare functions.

“Days” means Federal business days unless otherwise specified.

“Denied Claim” means a claim that has been fully adjudicated. The contractor determines that payment on the claim shall not be made, either in full or in part. Denials are made based on Medicare rules and regulations.

“Determination” - see “Initial Determination,” “MSP Determination,” or “"Determination of Program Eligibility."

"Determination of Program Eligibility" means a CMS action that determines whether a prospective provider that must execute a health insurance benefits agreement meets all federal requirements necessary for participation in the Medicare program and is eligible to submit claims for covered services furnished to Medicare beneficiaries. A determination of Program Eligibility is based on satisfactory completion of the provider enrollment process, a certification of compliance, and a civil rights clearance.

“Developing claims” means the contractor must seek information from external sources, such as beneficiaries and providers, in order to adjudicate a claim.

“Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS)” means a medical equipment that is ordered by a doctor for use in the home. These items must be reusable, such as walkers, wheelchairs, or hospital beds. DMEPOS is a Part B benefit paid for by Special Purpose MACs, either DME MACs or Home Health MACs.

“Durable Medical Equipment Medicare Administrative Contractor” (DME MAC) means a MAC contractor that processes DMEPOS claims.

“DMERC Information Form” (DIF) means a document containing information required by the carrier to be submitted to show that an immunosuppressive drug is reasonable and necessary. DIFs contain questions that reflect the local medical review policy for the item being billed. DIFs also require other types of administrative information that is useful for the DME MAC or other entity to ensure that the item billed was reasonable and necessary.

“Effectuate” means to pay for an item or service after an initial determination has been reversed on appeal or administrative law judge (ALJ) decision.

“Field Audit” means the performance of prescribed procedures in the examination and verification of data maintained by the provider. It encompasses a written record of the work performed and the results.

“Finalized status” means a final decision to pay, pay in part, or deny a claim.

“Fraud and Abuse Complaints” means a statement, oral or written, alleging that a provider, supplier, or beneficiary received a Medicare benefit of monetary value, directly or indirectly, overtly or covertly, in cash or in kind, to which he or she is not entitled under current Medicare law, regulations, or policy. Included are allegations of misrepresentation and violations of Medicare requirements applicable to persons or entities that bill for covered items and services.

“Function” means a unique operation, which is separately identifiable, such as Claims and/or Bills Payment, Appeals, etc. Functions consist of a series of activities.

“Functional Requirement” means a requirement that is part of the Medicare Operations process such as Bills Payment, Appeals, and Medical Review, etc… Each functional area represents a unique operation consisting of activities driven by Agency requirements outlined in the Medicare manuals.

“Good cause” means a legally sufficient ground or reason exists to take a specific action, principally in the claim appeals process.

“Health Insurance Claim Number” (HICN) means the number assigned by the Social Security Administration to an individual identifying him/her as a Medicare beneficiary. This number is shown on the beneficiary’s insurance card and is used in processing Medicare claims for that beneficiary.

“Implementation” means the period of time beginning with the award of the MAC contract and ending with the operational date of the MAC. During this period, the MAC performs all of the activities specified in its implementation project plan to ensure the effective transfer of Medicare functions from the outgoing contractor(s). See “Workload Transition.”

“Implementation Guide” (IG) means a document explaining the proper use of a standard for a specific business purpose. The X12N HIPAA IGs are the primary reference documents used by those implementing the associated transactions, and are incorporated into the HIPAA regulations by reference.

“Incomplete/invalid claims” means claims that are missing critical information (e.g., HICN, procedure code) and therefore do not meet the definition of a claim. Such claims are returned to the provider and may be corrected and resubmitted, but do not have appeal rights.

“Inherent Reasonableness” (IR) means an authority granted to CMS whereby excessively high or low fee schedule amounts can be adjusted to more fairly represent the market.

“Initial Determination” generally means a decision made to pay in full, pay in part, or deny a claim. However, there are other actions that are also considered initial determinations and there are specific regulatory provisions defining what constitutes an “initial determination for purposes of fee-for-service administrative appeal rights attaching. See specifically 42 CFR 405.924 and 405.926.

“Interface” means an entity the contractor must interact with to ensure consistency of Medicare program operations.

“Interface Requirement” means a requirement that necessitates a mechanism (e.g., contract clause, Joint Operating Agreements (JOA), Service Level Agreements (SLA)) to address ongoing activities contractors must conduct, entities they must interact with to ensure consistency of Medicare program operations. When there are interdependencies, these requirements serve to ensure that all parties understand their respective responsibilities.

“Joint Operating Agreement” (JOA) means an agreement between two or more contractors working for CMS who must interact with each other on an equal basis. CMS may or may not be a signatory to the JOA, depending on the confidence we have that the parties will self-police the agreement, and depending on the advice of OGC.

“Jurisdiction” means (1) the geographic territory, which the MAC will serve, and/or (2) the types of services that a contractor processes.

“Jurisdiction Operational Start Date” means the date that the MAC contractually assumes the Medicare functions from all outgoing carriers/intermediaries in its jurisdiction.

“Letter-of-Credit” means a legal reservation of funds on deposit in the Federal Reserve Bank (Standard Form 1193) that covers payments for which the contractor has contracted to pay by issuing checks and authorizing electronic funds transfer.

“Limitation of Liability” (LOL) means a restriction on liability for payment protecting either Medicare beneficiaries or providers based on Sections 1870 and 1879 of the Act.

“Local system edits” means adaptations to the shared system, approved by CMS, and made by the contractor, to—

· Communicate with providers via remittance advice and beneficiaries via Medicare Summary Notice (MSN),

· Implement local coverage determinations, and

· Workaround shared system limitations.

“Material Weakness” means failing to meet a control objective due to a significant deficiency in the design and/or operation of internal control policies and procedures.

“Medicare Reimbursement Principles” means the Medicare cost reimbursement principles as set forth at 42 CFR 412.113.

“Medicare Secondary Payer” (MSP) means a series of statutory provisions that require other payers (including those that are self-insured) of medical items and services (e.g., group health plans, liability and no-fault insurers) to make payment before Medicare pays when certain specific conditions are satisfied.

“Medicare Summary Notice” (MSN) means a monthly notice that a beneficiary receives once a claim has been filed for either Part A or B services with the MAC. It provides an explanation of what the provider billed for, how much Medicare paid and the amount that is the beneficiary’s responsibility.

“MSP Claims Determination” means the determination to deny payment or to pay conditionally due to an MSP situation.

“MSP Settlement” means, in the context of Medicare Secondary Payer appeals, the trigger event for a Medicare Secondary Payer recovery claim.

“National Provider Identifier” (NPI) means a standard unique identifier for providers. The NPI is a numeric 10-digit identifier adopted by HHS as the standard identifier for health care providers. Currently, the NPI is scheduled to replace the UPIN in 2007.

“National Supplier Clearinghouse” (NSC) means a contractor that enrolls Medicare DMEPOS suppliers.

“Next Generation Desktop” (NGD) means a government furnished, Web-based customer service desktop application.

“Orthotics” means appliances, that are covered under Part B when furnished incident to physicians’ services or on a physician’s order. A brace includes rigid and semi-rigid devices, which are used for the purpose of supporting a weak or deformed body member or restricting or eliminating motion in a diseased or injured part of the body. Elastic stockings, garter belts, and similar devices do not come within the scope of the definition of a brace. Back braces include, but are not limited to, special corsets (e.g., sacroiliac, sacrolumbar, dorsolumbar corsets) and belts. A terminal device (e.g., hand or hook) is covered under this provision when an artificial limb is required by the patient. Stump stockings and harnesses (including replacements) are also covered when these appliances are essential to the effective use of the artificial limb.

“Other Than Clean Claims” Any claim that does not meet the definition of clean claim above. These are complete claims that require manual intervention on the part of the contractor to be adjudicated. (These are sometimes also called “dirty claims.”)

“Paid Claims Error Rate” means a rate that is based on dollars paid after the contractor made its payment decision on the claim/admission. It excludes any claim/admission that the contractor completely disallowed (CMS has reviewed the impact of these exclusions and determined that they have a negligible effect on the error rate.). The paid claims error rate is the percentage of dollars that contractor erroneously allowed to be paid and is a good indicator of how claim errors in the Medicare FFS program impact the trust fund. This error rate is based on dollars.

“Performance Requirement” means a clear and concise statement of a desired outcome. In this statement of work performance requirements are identified as numbered subparagraphs in Section C.5.

“Performance Standards” means a defined level of (expected) performance against which the quality of the contractor’s services can be determined.

“Performance Measure” means a clearly defined qualitative or quantitative method for determining the level of performance that a contractor has actually achieved.

“Periodic Review” means CMS reviews conducted at times determined to be appropriate for the circumstances.

“Post-Cutover Period” means: The MAC’s first three months of Medicare operations, during which workload and performance are monitored and any problems with the implementation are resolved.

“Program Safeguard Contractors” (PSC) means a contractor that performs specific program integrity functions under Section 1893 of the Act such as audit, medical review, and potential fraud and abuse investigations and case referrals, and some specialty functions (e.g., CERT, DAVE, etc.).

“Prosthetics” means devices (other than dental) which are covered under Part B as a medical or other health service (§1861(s)(8) of the Act) and are devices that replace all or part of an internal body organ or replace all or part of the function of a permanently inoperative or malfunctioning internal body organ. Replacements or repairs of such devices are covered when furnished incident to physicians’ services or on a physician’s orders.

“Provider” means any Medicare provider (e.g., hospital, skilled nursing facility, home health agency, outpatient physical therapy, comprehensive outpatient rehabilitation facility, end-stage renal disease facility, hospice, physician, non-physician provider, laboratory, supplier, etc.) providing medical services covered under Medicare Part B. Any organization, institution, or individual that provides health care services to Medicare beneficiaries. Physicians, ambulatory surgical centers, and outpatient clinics are some of the providers of services covered under Medicare Part B.

“Provider Contact Center” (PCC) means a provider customer service center responding to telephone and written provider inquiries.

“Prospective Payment System” (PPS) means a method of reimbursement in which Medicare payment is made for certain institutional benefits based on a predetermined, fixed amount. The payment amount for a particular service is derived based on the classification system of that service.

“Qualified Independent Contractor” (QIC) means a contractor that performs reconsiderations of the contractor's initial determinations and redeterminations of Medicare claims.

“Quarterly Releases” means four quarterly software releases (generally released on the first Monday of the calendar year quarters) used to implement changes to the Shared Systems and the CWF.

“Reconsideration” means the second level of the Medicare fee-for-service claims appeals process. It is an independent review of the redetermination decision, including the initial determination, and is conducted by a Qualified Independent Contractor (a separate entity from the Medicare Agency and the Medicare contractor). The person conducting the reconsideration must not have been involved in either the initial determination decision or the redetermination decision.

“Recovery claim” means certain debts (particularly Medicare Secondary Payer debts) owed to the Medicare program.

“Redetermination” means the first level of the Medicare fee-for-service claims appeals process. It is an independent review of the initial claims determination and is conducted by the Medicare contractor. The individual(s) conducting the redetermination must not have been a part of the initial determination decision. A redetermination decision is considered to be part of the initial determination.

“Rejected claim” means a claim that fails a CWF edit that the contractor must resolve until the claim is paid, denied, or returned

“Returned claim” means a claim that is returned to the provider without the contractor making a determination to pay or deny the claim. There are no appeal rights.

“Regional Home Health Intermediary” (RHHI) means a business entity that contracts with Medicare to pay home health and hospice bills and check on the quality of home health and hospice care.

“Service Level Agreement” (SLA) means a written document between a provider of a service (e.g. data center, cable company, telecommunication company) and its customer about the quality, quantity and timeliness of the delivery of the product or service the customer is buying.

“Services Processed Error Rate” means a rate that is based on services processed and measures whether the contractor made appropriate payment decisions on claims. All sampled claims are included (whether the contractor paid or denied them). This is a gross rate where the number of services overpaid is added to the number of services underpaid. The services processed error rate is a good indicator of how well the contractor is doing overall at finding and preventing claim errors. This error rate is based on numbers of services.

“Shared System”(Previously known as Standard System) means systems provided by CMS to process Medicare claims. For professional claims (e.g., physician claims), the system is Multi Carrier System (MCS); for institutional providers (e.g., hospital nursing homes), the system is the Fiscal Intermediary Standard System (FISS), and for DME MACs, the system is the ViPS Medicare System (VMS).

“Skilled Nursing Facility” (SNF) means a facility (which meets specific regulatory certification requirements) which primarily provides inpatient skilled nursing care and related services to patients who require medical, nursing, or rehabilitative services but does not provide the level of care or treatment available in a hospital.

“Small Provider” means a provider of services with fewer than 25 full time equivalent employees or a supplier with fewer than 10 full time equivalent employees.

“Stakeholders” means beneficiaries, care givers, beneficiary family members, advocacy groups, providers, insurers, Medicare contractors, industry associations, employers, other third party administrators, other third party payers, data users, standards setting organizations, CMS, Medicaid, HHS, the HHS Office of the Inspector General, other Government Agencies, the General Accounting office, Congress, and taxpayers.

“Supplier” means a provider that generally provides supplies (e.g., DMEPOS, pharmacy) and/or specific medical services (i.e., independent diagnostic testing facility, laboratory services, and ambulance services). As used in this SOW, the term “provider” encompasses “supplier.” See “Provider.”

“Supplier Complaint” means a provider’s complaint about the MAC’s performance. Provider complaints are used as a measure of the quality of the MAC’s performance under this SOW.

“Suspended claim” means a claim that is flagged by the claims processing system and must be resolved before the claim can be processed to completion. On the institutional side, a suspension can occur due to a code placed on the claim by the provider.

“System Development Life Cycle” (SDLC) means the process of developing information systems through investigation of the need, requirements analysis, design, testing, and implementation. SDLC is also known as information systems development or application development.

“System Security” means protecting any Federal information and information systems, which include information technology (IT) systems, from unauthorized access, use, disclosure, disruption, modification, or destruction.

“Transition Requirements” means requirements that encompass all of the tasks an incoming contractor must perform to assume from a current contractor all aspects of its Medicare fee-for-service claims processing operation.

“Technical Advisory Group (TAG)” means a workgroup containing experts in the subject area and generally including staff from the contractor, CMS central and Regional offices, other MACs and the shared systems maintainers.

“Unique Physician/Practitioner Identification Number” (UPIN) means a unique identifier for each physician, practitioner or group practice that provides services for which Medicare payment is made. Currently, the UPIN is scheduled to be replaced by the NPI in 2007.

“VMS Standard System” means the ViPS Medicare system used to process DMEPOS claims.

“Workload Transition” means the entire scope of activities associated with moving Medicare functions from one, or several, Medicare contractor(s) to another. See “Implementation.”

B.

ACRONYM LIST

Acronym

Definition

ABC

Activity Based Costing

AC

Activity Code

ACD

Automatic Call Distribution

ACW

After Call Work

ADMC

Advance Determination of Medical Coverage

ADR

Additional Documentation Request

AGNS

AT&T Global Network Services

AHFI

Accredited Healthcare Fraud Investigator

AIC

Amount in Controversy

ALJ

Administrative Law Judge

AMA

American Medical Association

ANSI

American National Standards Institute

API

Application Program Interface

ASC

Accredited Standards Committee

ASCA

Administrative Simplification Compliance Act

ASO

Administrative Services Organizations

ASP

Average Sales Price

ATB

All Trunks Busy

AUSA

Assistant United States Attorney

AWP

Average Wholesale Price

BCBSA

Blue Cross and Blue Shield Association

BCC

Beneficiary Contact Center

BFE

Business Function Expert

BI

Benefit Integrity

BIPA

Medicare, Medicaid and SCHIP Benefits Improvement and Protection Act of 2000

BIU

Benefits Integrity Unit

BNS

Beneficiary Network Services

BPRs

Budget and Performance Requirements

BPSSM

Business Partner Systems Security Manual

CAC

Carrier Advisory Committee

CAP

Corrective Action Plan

CAFM

Contractor Administrative, Budget and Financial Management

CCUG

Call Center User Group

CD

Compact Disc

CERT

Comprehensive Error Rate Testing

CF

Conversion Factors

CFE

Certified Fraud Examiner

CFO

Chief Financial Officer

CFR

Code of Federal Regulations

CICS

Customer Information Control System

CIM

Coverage Issues Manual

CMD

Contractor Medical Director

CMN

Certificate of Medical Necessity

CMS

Centers for Medicare & Medicaid Services

CO

Central Office

COB

Coordination of Benefits

COBAs

Coordination of Benefits Agreements

COBC

Coordination of Benefits Contractor

COOP

Continuity of Operations Plan

COTR

Contracting Officer Technical Representative

CPE

Contractor Performance Evaluation

CPIC

Certification Package for Internal Controls

CPT

Claims Processing Timeliness

CPT

Current Procedural terminology

CR

Change Request

CROWD

Contractor Reporting of Operational and Workload Data

CSAMS

Customer Service Assessment and Management System

CSE

Claim Submission Error

CSP

Customer Service Plan

CSR

Customer Service Representatives

CTI

Computer Telephony Integration

CWF

Common Working File

DAB

Departmental Appeals Board

DAC

Data Analysis and Coding (formerly the SADMERC)

DAC

Deployment Assistance Center

DAP

DME MAC Advisory Process

DBID

Data Bank ID

DCIA

Debt Collection Improvement Act

DCS

Debt Collection System

DMD

DME MAC Medical Director

DME

Durable Medical Equipment

DMEPOS

Durable Medical Equipment, Prosthetics, Orthotics and Supplies

DME MAC

Durable Medical Equipment Medicare Administrative Contractor

DMOPTAG

DME MAC Operations Technical Advisory Group

DNF

Do-Not-Forward

DNIS

Dialed Number Identification Service

DOJ

Department of Justice

DOR

Date of Receipt

DPP

Disproportionate Patient Percentage

ECRS

Electronic Correspondence Referral System

EDB

CMS Enrollment Database

EDI

Electronic Data Interchange

EIN

Employee Identification Number

EMC

Electronic Media Claim

EOB

Explanation of Benefits

ERP

Extended Repayment Plan

ERRP

Error Rate Reduction Plan

ESRD

End Stage Renal Disease

FAQ

Frequently Asked Questions

FBI

Federal Bureau of Investigations

FFS

Fee for service

FISS

Fiscal Intermediary Standard System

FMFIA

Federal Manager's Financial Integrity Act of 1982

FOIA

Freedom of Information Act

FSA

Focused Study Areas

FTCA

Federal Tort Claim Act

FTE

Full Time Equivalent

FTS

Federal Telephone Service

FY

Fiscal Year

GAO

General Accounting Office

GHP

Group Health Plan

GPO

Government Printing Office

GPRA

Government Performance and Results Act

GSA

General Services Administration

GTL

Government Task Leader

HCPCS

Health Care Common Procedure Coding System

HGTS

Harkin Grantee Tracking System

HI

Hospital Insurance

HIAA

Health Insurance Association of America

HIC #

Health Insurance Claim

HIMR

Health Insurance Master Record

HIPAA

Health Insurance Portability and Accountability Act

HIPDB

Healthcare Integrity and Protection Data Bank

HO

Hearing Officer

HRSA

Health Resources and Services Administration

HTML

HyperText Markup Language

HUBC

CWF Part B Claim Record

HUCM

Maintenance Transaction Record

HUDC

DMEPOS Claim Records

ICN

Inter-contractor Notices

ICR

Image Character Recognition

IDIQ

Indefinite Delivery/Indefinite Quantity

IEQ

Initial Enrollment Questionnaire

IER

Interim Expenditure Report

IG

Implementation Guide

IICS

Inflation Indexed Charges

IOM

Internet-Only Manual

IP

Internet Protocol

IRS

Internal Revenue Service

ISO

International Organization for Standardization

IP

Internet Protocol

IT

Information Technology

IT

Internet Architecture

ITR

Intent to Refer

IVRs

Interactive Voice Response Units

JOA

Joint Operating Agreement

LAN

Local Area Networks

LCD

Local Coverage Determinations

LMRPs

Local Medical Review Policies

LPET

Local Provider Education and Training

LPN

Licensed Practical Nurse

LRO

Lead Regional Office

LU

Logical Unit

MBR

Master Beneficiary Record

MCD

Medicare Coverage Database

MCS

Multi Carrier System

MCSC

Medicare Customer Service Center

MDCN

Medicare Data Communications Network

MED

Medicare Exclusion Database

MEDPARD

Medicare Participating Physician Supplier Directory

MFMM

Medicare Financial Management Manual

MIP

Medicare Integrity Program

MMA

Medicare Prescription Drug, Improvement and Modernization Act of 2003

MOU

Memorandum of Understanding

MPARTS

Mistaken Payment Recovery Tracking System

MR

Medical Review

MSN

Medicare Summary Notice

MSP

Medicare Secondary Payer

MSPPAY

Medicare Secondary Payment Module

NA

Not Applicable

NCD

National Coverage Determinations

NCOA

National Change of Address

NCPDP

National Council for Prescription Drug Programs

NDC

National Drug Codes

NDM

Network Data Mover

NF

Nursing Facility

NGD

Next Generation Desktop

NOBA

Notice of Budget Approval

NSC

National Supplier Clearinghouse

NSF

National Standard Format

OACD

Oral Anti-Cancer Drug

OAS

Office of Analysis and Systems

OBRA

Omnibus Budget Reconciliation Act

OCA

Office of Contract Administration

OCR

Optical Character Recognition

OGC

Office of General Counsel

OHA

Office of Hearing and Appeals

OIFO

Office of Investigations Field Office

OIG

Office of the Inspector General

OMB

Office of Management and Budget

OSA

Out of Service Area

OSCAR

Online Survey Certification & Reporting System

OTR

On-the-Record

P & O

Prosthetics and Orthotics

PAL

Provider Audit List

PAR

Participating Supplier

PC

Personal Computer

PCA

Progressive Corrective Action

PCC

Provider Contact Center

PCOM

Provider Communication

PDF

Program Development Facility

PECOS

Provider Enrollment, Chain and Ownership System

PEM

Provider Enrollment Manual

PEN

Parental and Enteral Nutrients

PET

Provider Education and Training

PIM

Program Integrity Manual

PM

Program Memorandum

POC

Point of Contact

PPS

Prospective Payment System

PSC

Program Safeguard Contractor

PSOR

Physician / Supplier Overpayment Report

PTS

Provider Tracking System

PVC

Private Virtual Connection

QA

Quality Assurance

QAR

Quarterly Activity Reports

QCM

Quality Call Monitoring

QI

Quality Improvement

QIC

Qualified Independent Contractor

QIO

Quality Improvement Organization

QPU

Quarterly Provider Update

QSA

Quarterly Strategy Analysis

QWCM

Quality Written Correspondence Monitoring

RA

Remittance Advice

RAND

Random Number Generator

REMAS

Recovery Management & Accounting System

RHHI

Regional Home Health Intermediary

RMRP

Regional Medical Review Policy

RN

Registered Nurse

RO

Regional Office

ROM

Read Only Memory

RRB

Railroad Retirement Board

RVS units

Relative Value Scale Units

SADBUS

Small & Disadvantaged Business Utilization Specialist

SADMERC

Statistical Analysis Durable Medical Equipment Regional Carrier

SACC

Statistical Analysis Coordinating Committee

SACU

Supplier Audit and Compliance Unit

SAS

Statement on Auditing Standards

SDB

Small & Disadvantaged Business

SFR

Store-and-Forward Repository

SHIPs

State Health Insurance Assistance Programs

SMI

Supplementary Medical Insurance

SNA

System Network Architecture

SNF

Skilled Nursing Facility

SOP

Standard Operating Procedures

SOW

Statement of Work

SPCOM

Supplier / Provider Communications

SSA

Social Security Administration

S/PSP

Supplier / Provider Service Plan

SVRSs

Statistically Valid Random Samples

TCP

Transmission Control Protocol

TDD

Telecommunications Device for the Deaf

TPA

Third Party Administrator

TPA

Trading Partner Agreement

TSIT

Total Sign-In Time

TTY

Teletypewriter (Text Telephones)

UPIN

Unique Physician Identification Number

USPS

US Postal Service

VMS

VIPS Medicare System

WC

Workers Compensation

C.

REQUIREMENTS FOR THE ONLINE CLAIMS STATUS CAPABILITY

The status information should, at minimum, provide:

A. Claim Status – indicate the status for the queried claim using the following values:

05 – claim not found

06 – claim transferred to Region A

07 – claim transferred to Region B

08 – claim transferred to Region C

09 – claim transferred to Region D

10 – in progress

20 – development

30 – medical and utilization review

40 – services review

60 – reply resolution

70 – complete, paid

80 – complete, no payment

90 – complete, rejected

B. Health Insurance Claim Number (HICN)

C. Beneficiary Name

D. Medical Record Number

E. Amount Paid

F. Amount Paid to Biller

The DME MAC shall provide claims status inquiry functions with the following minimum features:

A. Query screens for electronic billers to enter key field data such as requested HICN and dates of service.

B. Formatted screen display for terminal.

C. Sends out electronic claims status messages and receives claim inquiry messages.

D.

DATA RELEASE POLICIES AND PROCEDURES

General

This section specifies the procedures that the Contractor shall follow under each of the Privacy Act (PA) data release provisions. The Centers for Medicare & Medicaid Services (CMS) is in the process of updating these procedures to incorporate privacy regulations of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and this appendix is subject to change upon their completion.

Release of Data with Individual’s Consent

An individual may have access to any record maintained on him/her in a system of records. The Contractor shall provide such access upon receipt of a request in writing and verification of the individual’s identity. The individual may request that data being maintained be sent to another party. Contractor staff will send the data upon receipt of a completed Consent Statement. No fee will be charged for searching for an individual’s personal record or for a photocopy when a copy must be made in order to provide access to the record.

Release of Identifiable Data Within CMS and Within Health and Human Services

3.1 General

Identifiable data may be released within an agency from one employee to another employee on a need-to-know basis. That is, the requesting employee must need the data in identifiable form in order to perform his/her duties. The Department of Health and Human Services (HHS) is considered to be a single agency.

3.2 Release Within CMS

Within CMS, both non-identifiable and identifiable data may be obtained from the Office of Information Services (OIS) by completing a Request for Information form. If identifiable data are requested, OIS will generally accept the CMS component’s determination that the data are needed in identifiable form unless it is obvious that more data are being requested than necessary or the data requested are unrelated to the purpose of the request. If the component intends to re-release the data to a contractor/grantee or other non-government entity, the CMS component and the non-government source must sign an Agreement for Release of Data with Individual Identifiers, binding the user to protect the confidentiality of the data. The agreement must be signed and must accompany the Request for Information form before data are released.

3.3 Release Within HHS

Requestors outside of CMS, but within the Department of Health and Human Services, can also receive individually identifiable data on a need-to-know basis. CMS requires HHS agencies to meet the same criteria as are specified under the subsection Basic Routine Uses, below, and also to follow the same process. An exception to this is the approval of a research project by the component’s review panel, which will be accepted as establishing that the project is important and soundly designed. If the component plans to complete the research project in-house, the component will be required to sign a Federal Agreement for Release of Data with Individual Identifiers. There may be a charge for providing data.

Release of Identifiable Data Outside of the Department for Purposes Compatible With Program Objectives (Routine Uses)

4.1 General

Identifiable data may be released outside HHS without the beneficiary’s consent for “routine uses” that have been published in the Federal Register as part of the notice of the system of records containing the requested data. Routine uses must be compatible with purposes for which the data in the system were initially collected. Most of CMS’ routine uses are necessary in order to operate the Medicare/Medicaid programs: release to state welfare agencies, Quality Improvement Organizations, providers and suppliers, and state audit agencies, and to the Justice Department for litigation. A number of CMS components have routine uses for release of data for health research, for analysis of Medicare payment policies, for data processing by contractors, for determination of the quality and effectiveness of hospital care, for state agency cost containment, for Medicare hospital mortality analysis, and for other uses compatible with CMS’ mission. An outline of common routine uses follows. It should be noted that there is a charge, in most cases, for data released under a routine use.

4.2 Basic Routine Uses

4.2.1 Research Routine Use

Identifiable data may be released to an individual or organization for a health-related research evaluation or epidemiologic project when certain criteria (below) are met and a specific process is followed. (This provision for release of data is contained in System of Records notices for a number of CMS’ major data systems.)

4.2.1.1 Criteria

Purpose requires individually identifiable records.

Project is of sufficient importance to warrant effect, or risk, on beneficiary privacy.

There is reasonable probability that use of data will accomplish purpose, i.e., project is soundly designed and properly financed.

Data will be protected and identifiers removed as soon as possible.

Requester signs agreement to abide by CMS’ data release policies and procedures.

4.2.1.2 Procedures to Obtain Data for Research Purposes

Request is sent to the appropriate CMS component explaining purpose of the project, data needed, and how data would be used. The following documentation should accompany the request:

Copy of research or evaluation protocol or detailed project plan that will be reviewed by research experts to determine if criteria are met.

Copy of report of review by panel of scientists (if applicable).

Copy of form (face sheet of grant/contract/cooperative agreement) showing that the project is funded.

Documentation will be reviewed:

To determine that data requested are available.

By an appropriate CMS component to determine that the criteria are met. (This process takes approximately 6 weeks.) Approval by review panel of experts outside of CMS may be accepted as proof that the criteria are met.

If all criteria are met, a data release agreement will be sent to the requester(s) for signature(s).

This routine use may be used to release data under a CMS contract/grant/cooperative agreement. The component must obtain a copy of the data release agreement (or use a similar agreement that protects data confidentiality). The component and the contractor sign the agreement. A copy of the agreement must be sent to OIS where a master database of all CMS agreements is maintained.

When the names and/or addresses of beneficiaries are requested to solicit them for participation in a research project not funded by CMS, a letter over the Administrator’s signature must be sent to each beneficiary.

4.2.2 Data Processing Contractor Routine Use

This routine use permits release of identifiable data to CMS contractors for the purpose of data processing: collating, analyzing, aggregating, or otherwise processing data. Data would also be disclosed incidental to consultation, programming, operation or user assistance. Contractor employees are required to sign statements agreeing to protect the data. (This provision is included in System of Records notices for all of CMS’ major data systems.)

4.2.3 Quality and Effectiveness of Care MEDPAR (QC/MEDPAR) Routine Use - OIS Only

OIS will release the QC/MEDPAR to entities for research on, and evaluation of, the quality and effectiveness of care provided in hospitals. The focus must be on measures of determining, validating, evaluating, and monitoring quality and effectiveness in such areas as access and outcomes. A major difference between the characteristics of this file and the EXMM file is that the ZIP code of the beneficiary’s residence is provided, and an encrypted beneficiary health insurance account number is included, making it possible to follow the beneficiary from month to month and year to year.

4.2.3.1 Criteria

The research and/or evaluation purpose requires data in detailed form as provided in the file.

The purpose is likely to be accomplished in light of requesting entity’s capabilities and other factors.

The purpose is of sufficient importance to warrant effect on and risk to beneficiary privacy.

4.2.3.2 Procedures to Obtain Data

Entity must submit to OIS, and CMS must approve the following:

A research and/or an evaluation plan specifying the objectives of the research and/or evaluation, how data will be used, financial support, and completion date.

A copy of report by panel of experts on review of plan (where such a review was performed).

Upon receipt of the above:

The appropriate CMS component will review the plan and the documentation, determine if criteria are met, and provide a recommendation to OIS on release.

Requester will be required to sign QC/MEDPAR data release agreement.

Requester will be required to send a certified check/money order for the cost of the QC/MEDPAR file.

4.2.4 State Agency Cost Containment and Quality and Effectiveness of Care Routine Use

CMS may release data with individual identifiers to a qualified state agency for purposes of determining, evaluating and/or assessing cost, effectiveness, and/or quality of health care services provided in the state. Release of the data is governed by the routine use published in the Federal Register on Thursday, December 29, 1988, page 52792. The agency must meet the criteria listed below and also follow the procedures specified below:

4.2.4.1 Criteria

Requesting organization must be an agency of a state government or established by state law.

The data must be requested and used for the purpose of determining, evaluating and/or assessing cost, effectiveness and/or the quality of health care services provided in the state.

Use or disclosure of the data must not violate legal limitations under which the data were provided, collected, or obtained.

Once received by agency, data must be exempt from disclosure under any state/local Freedom of Information Act.

Data with individual identifiers must be required to accomplish agency purposes.

Agency purpose must be of sufficient importance to warrant effect and/or risk on beneficiary’s privacy.

It must be reasonable to expect that the agency will be able to accomplish its purposes in using the data.

4.2.4.2 Procedures to Obtain Data that State Agency Must Submit

State agency must submit:

Documentation that it is a part of the state government or established by state law, e.g., submit a copy of enabling legislation.

A copy of its operating plan that provides detail about goals, strategy, and activities that are being carried out and/or planned to accomplish goals, including periodic reports. It must be clear how CMS data would be used.

Evidence that data would be exempt from any state or local Freedom of Information Act (FOIA).

Signed data release agreement stipulating that state agency:

Will not use data for other purposes.

Will not publish data in a form permitting deduction of individual identities.

Will submit a copy of aggregated data or proposed table shells to CMS prior to publication.

Will make no further disclosure except for emergencies, to another CMS-approved project, or for official audits.

Will establish reasonable safeguards to protect data.

4.2.4.3 Expenses

As with other data released outside of CMS, there is a charge for data released to states.

4.2.5 Congressional Office Routine Use

Data with individual identifiers may be released to a Congressional office in response to an inquiry made by the individual to the member of Congress. A separate provision of the Privacy Act authorizes release to the Congress itself or to a committee of the Congress. This provision is included in System of Records notice for all of CMS’ major data systems. (See Release of Identifiable Data to the Congress, below.)

4.2.6 Bureau of the Census Routine Use

Data may be released to the Census Bureau to enable the Bureau to process research and statistical data for Social Security projects. A separate provision of the Privacy Act authorizes release of data for census purposes. This provision is included in System of Records notices for all of CMS’ major data systems. (See Release of Identifiable Data to the Bureau of the Census, below.)

4.2.7 Justice Department (or Court or other Tribunal) Routine Use

This routine use authorizes release of identifiable data to the Department of Justice (or a court) in litigation where the Department of Justice has agreed to represent an employee of HHS in his/her official or private capacity. (This provision is included in System of Records notices for all of CMS’ major data systems.)

4.2.8 Other Routine Uses

Various CMS systems have other routine uses in addition to those already mentioned in this subsection. For example, a new routine use was recently developed for OIS’s Medicare Bill File (Statistics). The new routine use permits the release of Medicare inpatient hospital data to allow an individual hospital to conduct mortality studies of its facility. As with all routine uses, there are specific procedures that hospitals must follow to obtain the data.

Due to the number of routine uses that evolve over time, and the specialized nature of each routine use, it is impractical to cover all of them in this guide. All routine uses are published in the Federal Register. A copy of the criteria for a particular routine use may be obtained by contacting the Privacy Act coordinator in the component that is designated the system manager.

Release of Identifiable Data to the Bureau of the Census

Data may be released to the Census Bureau for census-taking purposes, including making population estimates between census taking and as a cross-check of persons missing in census counts of aged persons. Release for census purposes is specifically authorized by a special disclosure provision in the Privacy Act. Release of data to the Census Bureau for research with which the Census undertakes to assist other federal agencies must be authorized under the provisions of the routine use described in the preceding section, Release of Identifiable Data Outside of the Department for Purposes Compatible with Program Objectives (Routine Uses). CMS does require Census to sign a Federal Agreement for Release of Individual Identifiable Data. CMS may also recover its processing costs.

Release of Statistical Data

Data that contain no individual identifiers or data elements that would permit the identity of a beneficiary to be deduced (e.g., date of birth, residence, ZIP code) may be released as statistical data. CMS releases many statistical tables containing aggregate data.

Release for a Civil or Criminal Law Enforcement Activity

CMS releases identifiable information in response to requests from any governmental agency for law enforcement activities authorized by federal, state, or local law, upon the request of the head of the law enforcement agencies specifying the data needed and the law to be enforced. Data have been released to a state health department enforcing a law requiring family approval before removing a deceased individual’s organs for transplant purposes. Data were also released to the Department of Justice for enforcement activity involving restraint of trade. Attorneys in the Office of General Counsel may be queried formally or informally if there is doubt about the request.

Release of Identifiable Data for the Health and Safety of the Individual

CMS may assist in the location of individuals where their health and safety is involved. For example, identifiable data were released to the Connecticut State Department of Health to locate individuals who had been exposed to benzene, a chemical that may cause bladder cancer. The employer was cooperating with the state in an effort to notify former employees of the possible danger and to offer an examination program. CMS has addresses for most individuals age 65 and over. Since few individuals under age 65 are Medicare beneficiaries, CMS coordinates with the Social Security Administration (SSA) to locate such individuals. SSA will forward a letter to the individuals at the individual’s last employer’s address.

Release of Identifiable Data to the Congress

Data may be released to either House of Congress or for purposes falling under its jurisdiction to any committee, subcommittee, or joint committee. Data are furnished to the Congressional Budget Office and the Library of Congress for Congressional projects. The Prospective Payment Assessment Commission and the Physician Payment Review Commission have separate legislation authorizing release of data to them.