Amendment 000001.pdf

RFP-CMS-2011-0026 A/B MAC Jurisdiction E Amendment 000001

The purpose of this amendment is to incorporate the following changes into the solicitation and provide responses to solicitation questions. The solicitation is amended as follows:

I. PART I – THE SCHEDULE

A. SECTION C – DESCRIPTION/SPECIFICATIONS/WORK STATEMENT.

The Statement of Work, amended January 6, 2011, is incorporated as Attachment J-01 and made a part of this solicitation. Subsection C.1, Statement of Work, is amended as follows:

1. SECTION C.1, SCOPE, is amended as follows:

The Contractor, as an independent Contractor and not as an agent of the government, shall furnish all the necessary services, qualified personnel, material, equipment, and facilities, not otherwise provided by the government, as needed to perform the work described in this Statement of Work (SOW).

The Contractor shall perform all Medicare Administrative Contractor (MAC) functions specified in this SOW and further defined in either the Internet-Only-Manuals (IOMs, http://www.cms.hhs.gov/Manuals/IOM/list.asp#TopOfPage) or the Paper-Based Manuals, in accordance with Section C.2.3 of this SOW. For purposes of this contract, when differences or conflicts occur, this SOW shall take precedence over the IOMs unless otherwise specified. The Contractor shall contact the Contracting Officer (CO) and the Contracting Officer’s Representative (COR) if budgetary concerns occur because of this conflict. The Contractor is advised that any and all references in the SOW (including manuals, IOMs, etc.) to “RO-Regional Office” shall be replaced with “CO-Contracting Officer” unless otherwise specified in this SOW. Appendix A contains definitions of all abbreviations used in this SOW.

2. SECTION C.5, FUNCTIONAL REQUIREMENTS, subsection C.5.4.1.11, Executive Contractor Medical Director (CMD) and Supporting CMDs, is amended as follows:

The Contractor shall employ a minimum of 3.0 full-time-equivalent (FTE) Contractor Medical Directors (CMDs) for this A/B MAC contract. The Contractor may meet the 3.0 FTE minimum by assigning fully-dedicated CMDs to this contract, by dedicating a portion of the time of several shared CMDs to this contract, or by assigning a combination of fully-dedicated and shared CMDs to this contract. These CMDs shall develop Local Coverage Determinations (LCDs), conduct medical review (MR) activities, provide clinical program outreach activities, take party or participant status in Administrative Law Judge (ALJ) appeals hearings, and perform other appeals and ALJ-related tasks as described in Section C.5.10.5 below.

http://www.cms.hhs.gov/Manuals/IOM/list.asp#TopOfPage

Among these CMDs, the Contractor shall assign one CMD to serve in an independent executive leadership role to provide overall leadership to all of the activities described in this section; this Executive CMD shall serve as key personnel under this statement of work.

The CMDs’ primary duties shall include:

Providing leadership in clinical program outreach to the practitioner/provider/supplier/beneficiary community, including:

• Interacting with medical societies and related peer groups;

• Educating physicians, providers, suppliers, beneficiaries, patient advocates and other relevant parties individually or as a group, regarding general and specific Medicare issues (e.g., Local Coverage Determinations, Medical Review); and,

• Acting as co-chair of the carrier advisory committee (CAC) (see PIM chapter 13 §13.7.1.4 for co-chair responsibilities).

Providing leadership in developing Local Coverage Determinations (LCDs) and related policies, including:

• Determining when new LCDs are needed;

• Determining when existing LCDs must be revised or retired;

• Determining that the coding (e.g., CPT/HCPCS/Revenue codes/bill type codes/ICD-9) correctly supports the LCD policy;

• Ensuring that LCDs are evidence-based;

• Selecting appropriately credentialed consultants in the pertinent fields of medicine to provide expert input into the development of LCDs; and,

• Understanding and applying medical evidence in determining whether an item or service is reasonable and necessary.

The CMDs shall participate in such activities that are determined by CMS to facilitate greater LCD consistency across A/B MACs when warranted by medical evidence. Such activities include:

• Additional CMD evidentiary meetings;

• Cross-jurisdictional CMD workgroups ; and,

• Structured review and analysis of medical evidence for written inclusion in every

LCD.

Providing leadership in developing policy articles, including

• Working within the Medicare claims contractor community to develop coding, payment, and documentation articles as necessary.

Providing leadership in developing and implementing Medical Review Quality Assurance Programs, including:

• Designing and conducting annual clinical judgment review training;

• Designing and conducting Inter-reviewer Reliability Assessments and corrective action programs; and,

• Keeping abreast of medical practice and technology.

Providing leadership in effectively focusing Medical Review (MR) and developing internal MR guidelines – this includes:

• Providing guidance to the development of the Error Rate Reduction Plan (ERRP);

• Providing guidance to the Annual Medical Review Strategy and the Strategy

Analysis Report;

• Providing guidance to identify areas of fraud and abuse including areas that create significant beneficiary safety or financial liability concerns;

• Serving as a witness or participant in Medicare claims-related proceedings before

Administrative Law Judges.

• Assuring that MR internal guidelines are evidence based;

• Providing technical assistance on the correct application of MR policy during claim adjudication, including through written internal claim review guidelines;

• Selecting consultants credentialed in the pertinent fields of medicine for expert input into the development of MR internal guidelines and for claim adjudication;

• Providing the clinical expertise to effectively focus MR on areas of potential fraud and abuse;

• Serving as a readily available source of medical information to guide Medical

Record reviews and other clinical inquiries; and,

• Conducting claim review where needed or appropriate.

Collaborating with CMDs at other Medicare Contractors (e.g., other MACs, Medicare fiscal intermediaries, Medicare carriers, Zone Program Integrity Contractors (ZPICs), Recovery Auditors, Qualified Independent Contractors (QICs), etc.) and with CMS, including

• Interacting with the CMDs at other contractors to share information on potential problem areas; and,

• Upon request, providing input to the CMS on Medical Review policy issues.

• Evaluating potential appeals hearing participation cases, and redetermination cases that are expected to continue through to an ALJ hearing, and recommending to the COR which cases CMS should elect party status as needed.

• Participating in ALJ hearing and other ALJ related tasks as described in C.5.10 below.

All CMDs assigned to this contract shall possess:

Experience

Prior clinical practice as an attending physician.

Work experience in the health insurance industry, a utilization review firm, or another health care claims processing organization in a role that involved developing coverage or medical necessity policies and guidelines.

Extensive knowledge of the Medicare program, particularly the coverage and payment rules.

Experience working with physician groups, beneficiary organizations, and/or congressional offices is preferred.

CMD candidates must also meet a requirement of never having been sanctioned or excluded from the Medicare Program.

Education/Licensure

The CMDs must be a board certified Doctor of Medicine or a Doctor of Osteopathy in a specialty recognized by the American Board of Medical Specialties. The CMDs must have been board certified for at least 3 years. All clinicians employed or retained as consultants must also be currently licensed to practice medicine in at least one U.S. state, territory, or the District of Columbia. The contractor shall ensure that the CMDs and other physician consultants have active valid and unrestricted licenses.

3. SECTION C.5, FUNCTIONAL REQUIREMENTS, subsection C.5.4.8, Participation in Change Management Process, is amended as follows:

The Contractor shall actively participate in and support the CMS change management process in accordance with IOM Pub. 100-01, Chapter 7. NOTE: The Contractor’s participation in the CMS change management process begins upon the award of the contract.

http://www.cms.hhs.gov/Manuals/IOM/itemdetail.asp?filterType=none&filterByDID=-99&sortByDID=1&sortOrder=ascending&itemID=CMS050111 http://www.cms.hhs.gov/manuals/downloads/ge101c07.pdf

The Contractor shall review and comment on all draft Change Requests (CRs) issued by CMS and shall comply with all final CRs, including all revisions to the Internet-only manuals (IOMs). The Contractor shall provide a level of effort up to 46,200 hours per contract year with an increase of 3% for each subsequent year to (1) Participate in the Point of Contact (POC) Review process that is described in detail in Section C.5.4.8.1 of the SOW; (2) Implement CRs that require shared system changes; and (3) Implement CRs that do not require changes to the shared systems.

4. SECTION C.5, FUNCTIONAL REQUIREMENTS, subsection C.5.10.5, Administrative Law Judge Hearings, is amended as follows:

The contractor shall establish a process for assessing the notices of hearing received to determine which cases should be selected for participation. Factors to be examined should include, but not be limited to: policy implications, dollars at issue, program integrity matters, and the extent to which a particular issue is, or has been, a recurring issue at the ALJ level of appeal. Contractors need to be proactive in evaluating potential participation cases, and redetermination cases that are expected to continue through to an ALJ hearing and in some cases, should prepare a letter to include in the case file to indicate that they intend on participating if the case goes to a hearing.

C.5.10.5.1 Coordination

A notice of an ALJ hearing issued by OMHA will be sent only to the appropriate QIC.

Advance coordination with the QIC will be necessary to ensure the contractor receives timely notification, as the election to participate must be made no later than 10 days after receipt of the notice of hearing.

Since the QIC may also elect to participate in the ALJ hearing process, the contractor shall collaborate with the QIC regarding: coordination with OMHA on scheduling matters, the manner of participation, coordination on position papers or other written testimony submitted, and lessons learned from participation in the ALJ process. The contractor shall add procedural details involved with the coordination of representation at ALJ hearings into the existing joint operating agreement with the QIC

All relevant case file information, including information from other contractors regarding the claims at issue, must be obtained when the contractor elects to participate in the hearing as a participant or as a party. There may be cases in which testimony from another contractor is necessary. The contractor may call those entities as a witness only if the contractor has declared party status. However, if the contractor submits a position paper as a participant, the contractor may collaborate with other contractors and document their views on the case in the paper.

The contractor shall establish a single point of contact for ALJ offices on administrative matters involving notifications, scheduling, information sharing, and other coordination necessary between the ALJ, the appellant, and other contractors.

If another CMS contracting entity (e.g., ZPIC) indicates an interest in participating in a case, the MAC will coordinate participation in the case and roles and responsibilities of participation.

C.5.10.5.2 Participation in the ALJ Hearing

Contractors need to be proactive in evaluating potential participation cases, and in some cases, should prepare a letter to include in the case file to indicate that they intend on participating if the case goes to a hearing.

The election to participate shall be made consistent with the rules at 42 CFR 405.1010, and be provided in writing to the ALJ, appellant, and all parties identified, within 10 days of receipt of the notice of hearing (by the QIC). Participation may include filing position papers and providing testimony to clarify factual and policy issues involved in a case. The contractor shall be adequately prepared to respond to questioning by the ALJ (and by the appellant should the ALJ allow cross-examination) regarding all issues related to the claims under appeal.

Because participation status does not include the same rights as full party status, the contractor may not call witnesses, or cross-examine witnesses, of another party. The contractor must coordinate with other contractors in advance to solicit their participation should testimony from the other contractors be necessary.

C.5.10.5.3 Party in the ALJ Hearing

The contractor shall obtain approval from CMS prior to electing party status in an ALJ hearing. High priority will be given to cases involving program integrity matters and/or overpayment cases involving significant dollar amounts. Approval from CMS must be obtained prior to advising the ALJ and other parties of the intention to participate as a party. In the event that CMS does not approve the contractor’s request for party status, the contractor may elect to proceed as a participant.

The election for party status shall be made consistent with the rules at 42 CFR 405.1012, and provided to the ALJ, appellant and all parties identified within 10 days of receipt of the notice of hearing (by the QIC). As a party, the contractor may file position papers, call witnesses, and/or cross-examine witnesses of other parties. The contractor shall submit any position paper or additional evidence requested by the ALJ within timeframes established by the ALJ. A copy of any written statements must be provided to the other parties to the hearing at the same time they are submitted to the ALJ. The contractor shall be adequately prepared to respond to questioning by the ALJ or other parties regarding all issues related to the claims under appeal.

C.5.10.5.4 The ALJ Hearing

The ALJ sets the hearing date, time, and method by video teleconferencing (VTC), telephone, or in-person if VTC is not available or special circumstances exist.

Notice of the hearing will be sent to all parties and to the QIC. If the contractor intends to be either a participant or a party, they shall acknowledge that fact within 10 days of the date that the QIC received the notice of hearing. The acknowledgement notice shall be sent to the ALJ, the appellant, and all other parties identified in the notice of hearing. A party may object in writing to the time and place of the hearing, as soon as possible before the originally scheduled time, and include the reason for the objection along with a proposed alternative date and time. In addition, a party may request an in-person hearing by notifying the ALJ in writing and following the same procedures noted above for an objection to the time/place of the hearing. The ALJ may reschedule if good cause is established per 42 CFR 405.1020(f) or (g).

The contractor will actively participate in the ALJ hearing as appropriate based on participation status (participant or party). In either situation, the contractor must be prepared to discuss details related to the facts of each claim under appeal, the relevant coverage policies and payment requirements, including any clarification required on decisions made earlier in the appeals process. For post-pay audit/overpayment cases, the contractor must be prepared to discuss the background on how the supplier was selected for review, results of the sample case adjudications, as well as matters related to the extrapolation process.

C.5.10.5.5 Physician Participation

The contractor’s physician(s) for appeals hearing representation (.5 FTE)will participate in the Administrative Law Judge (ALJ) hearing process as a participant (see 42 CFR 405,1010) and recommend to the COR instances where they believe the MAC should invoke party status (see 42 CFR 405.1012). Further rules and procedures related to the

ALJ hearing process are contained in 42 CFR 405.1000. Physicians taking party or participant status may be a current CMD, a contractor employed physician or any combination, as long as there is .5 FTE designated for this work.

5. SECTION C.7, JURISDICTION-SPECIFIC REQUIREMENTS, subsection C.7.4, Rural Community Hospital Demonstration, is amended as follows:

The Contractor shall process claims and perform the requirements for the Rural Community Hospital (RCH) Demonstration in accordance with Change Request 7505, published on July 22, 2011. This Change Request details the requirements for the extension period of the demonstration, as mandated by Section 10313 of the Affordable Care Act.

The change request identifies the participating hospitals, MACs and legacy contractors.

For a summary of the demonstration and a list of participating hospitals, go to the following URL:

http://www.cms.gov/DemoProjectsEvalRpts/downloads/RCH_Summary.pdf

a. The MAC shall reimburse selected hospitals for inpatient services in accordance with the principles stated in Change Request 7505, as amended by the new Change Request.

b. As specified in CR 7505, the MAC shall conduct audits according to the principles expressed in IOM Pub. 100-06, Chapter 8. CMS expects that audits will be in-house audits.

Background

The Rural Community Hospital Demonstration Program was mandated by section 410A of the Medicare Prescription, Drug, Improvement, and Modernization Act of 2003. On August 27, 2010, HHS announced an expansion of the rural community hospital demonstration under Section 10313 of the Affordable Care Act. The Secretary is required to conduct the RCH Demonstration for an additional 5 year period to test the feasibility of establishing RCHs to provide Medicare covered inpatient hospital services in rural areas. This Demonstration will allow selected rural hospitals to benefit from cost-based reimbursement for inpatient services.

Currently, twenty-three (23) hospitals are participating in the demonstration program.

B. SECTION H, SPECIAL CONTRACT REQUIREMENTS, subsection H.3.c.2

Identification of Conflict, is amended as follows:

(a) The Contracting Officer determines that an Offeror or Contractor has a conflict of interest, or the potential for the conflict exists, if-

(1) The Offeror or Contractor is an entity described in paragraph H.3.c.2.c of this section; or http://www.cms.gov/DemoProjectsEvalRpts/downloads/RCH_Summary.pdf

(2) The Offeror or Contractor has a present, or establishes a future, direct or indirect financial relationship with an entity described in paragraph H.3.c.2.c of this section.

(b) A financial relationship may exist either—

(1) Through an Offeror's or Contractor's parent company, subsidiaries, affiliates, subcontractors, or current clients; or

(2) From the activities and relationships of the officers, directors (including medical directors), or managers of the Offeror or Contractor and may be either direct or indirect. An officer, director, or manager has an indirect financial relationship if an ownership or investment interest is held in the name of another but provides benefits to the officer, director, or manager.

Examples of indirect financial relationships are, but are not limited to, holdings in the name of a spouse or dependent child of the officer, director, or manager and holdings of other relatives who reside with the officer, director, or manager.

(c) For the purpose of identifying entities with conflicts of interest above, the entity is one that-

(1) Would review or does review, under the contract, Medicare services furnished by a provider or supplier that is a direct competitor of the Offeror or Contractor;

(2) Prepared work or is under contract to prepare work that would be reviewed under the A/B MAC contract;

(3) Is affiliated, as that term is explained in FAR 19.101, with a provider or supplier to be reviewed under the contract.

(d) The Contracting Officer may determine that an Offeror or Contractor has a conflict of interest, or the potential for a conflict exists, based on the following:

(1) Apparent conflicts of interest. An apparent conflict of interest exists if a person believes that the Offeror or Contractor would have a conflict of interest in performing the requirements of a contract under this subpart. No inappropriate action by the Offeror or Contractor is necessary for an apparent conflict of interest to exist.

(2) Other contracts and grants.

II. PART IV – REPRESENTATIONS AND INSTRUCTIONS

A. SECTION L, INSTRUCTIONS, CONDITIONS AND NOTICES TO OFFERORS,

is amended as follows:

1. SECTION L.8, PROPOSAL SUBMISSION AND DELIVERY, is deleted in its entirety and replaced with the following:

The Offeror shall deliver to the address below on or before Wednesday, January 25, 2012 by

2:00PM EST:

• Volume I – Written Technical Proposal – One (1) original, five (5) hard copies and one (1) CD-ROM

• Volume II – Business Proposal Cost Templates – One (1) original, five (5) hard copies and one (1) CD-ROM (Attachment J-07, Basis of Estimate, shall be provided as CD-ROM only)

• Volume IIB – Written Business Proposal – One (1) original, five (5) hard copies and one (1) CD-ROM

• Volume III – Conflict of Interest - One (1) original, (2) hard copies and one (1) CD-

ROM

• Each of the Proposal Volumes (I, IIA, IIB, and III), is submitted in their entirety in both hard copy and on CD-ROM, as stated above, in Microsoft Office Word or Excel

– Version 2007. The CD-ROM shall be placed in the box of “originals” as stated under L.9.j.

Signed annual reports and corporate policies may be submitted in Adobe Acrobat or PDF format.

Organizational charts may be submitted in Microsoft PowerPoint or Adobe version 2007.

Microsoft Project Files are acceptable (version 2007). However, in any case where a portion of the Offeror’s proposal is sent in Microsoft Project it must be accompanied by a PDF document that includes the same information.

The Offeror should submit its proposal PRINTED and COPIED DOUBLE-SIDED on RECYCLED PAPER to the greatest extent practicable to:

Centers for Medicare & Medicaid Services Office of Acquisitions and Grants Management Attn: Jason Vollmer, Contract Specialist 7500 Security Boulevard Mail Stop B2-14-21 Baltimore, Maryland 21244-1850

Offerors are hereby advised that the place for submission of proposals (*CMS Single Site at 7500 Security Blvd, Baltimore (Woodlawn), Maryland), is a secure building. Proposal delivery must be made to the exact location stated in this solicitation on or before the date and time specified. Offerors are also advised to make sure that the proposal is clearly marked as to:

A. The RFP number;

B. Jurisdiction Number;

C. The date and time for receipt;

D. The intended room location;

E. The intended recipient, and

F. The telephone number of the intended recipient

*See Attachment J-24 for directions to CMS Central Office (North Gate-Dogwood Road).

Offerors shall enter the CMS single site facility through the North Gate—Dogwood Road.

For security purposes Offerors shall contact the Contract Specialist or the Contracting Officer with the following information:

A. Delivery personnel name

B. Year, make, and model of delivery vehicle

C. Vehicle license plate number

D. Approximate number of boxes

The above information should be received by the Contract Specialist or the Contracting Officer at least 24 hours prior to delivery. If the above information is unknown 24 hours prior to delivery, the Offeror should provide the information as soon as it becomes available, but no later than 3 hours before proposal drop-off. Personnel will be asked to verify the above information at the North Gate-Dogwood Road prior to entering the CMS complex.

Upon verification, the delivery vehicle will be directed to the CMS warehouse, where proposals will be received. Delivery vehicles will not be searched at the North Gate- Dogwood Road so long as Offerors have supplied the above information and are placed on a pre-approved security list.

For logistical purposes only, Offerors should contact the Contract Specialist or the Contracting Officer to schedule a drop-off appointment. CMS will give Offerors preference for proposal delivery based on the number of jurisdictional proposals to be delivered and the number of boxes to be received. That is, CMS anticipates that an Offeror with a large number of boxes will be scheduled for proposal delivery early in the day.

Offerors who do not follow the above guidance when submitting proposals will be subject to standard security protocols prior to entering the CMS complex. Offerors will, at a minimum, be subject to a vehicle search and all packages/boxes and their contents may be opened and searched prior to entering the CMS complex.

Offerors are cautioned that proposals are considered ‘received’ by CMS when the Offeror receives a signed receipt by the Contract Specialist or Contracting Officer or their designees indicating the time and date of proposal receipt; which, if following the above guidance, will take place at the CMS warehouse.

Proposal delivery by a mail carrier service other than the U.S. Postal Service are not accepted in the CMS mailroom and therefore, Offerors’ proposals may not be delivered timely to the location and person specified in this solicitation.

Offerors are reminded that FAR 52.215-1 does not make allowance for proposals received late when submitted by mail services other than the U.S. or Canadian Postal Service.

Offerors are advised to take that possibility into consideration in determining when and how a proposal must be received at the specified location to meet the date and time requirements.

2. SECTION L.9, GENERAL INSTRUCTIONS, subsection L.9.i, Binding and Labeling, is amended as follows:

Offerors shall use three-ringed binders to submit proposals. A binder cover sheet shall be affixed to each volume, which clearly identifies each volume, volume number, copy number (i.e., copy 2 of 4), jurisdiction, the solicitation identification number, and the Offeror’s name. If the material for a volume requires more than one book, then that volume shall be labeled with the name and number of the volume and book number (i.e., Proposal, Book 1 of 2). The original of Volumes I, II, and III shall be marked ORIGINAL and all other copies shall be marked COPY # ___ of ___.

Proposals should be packaged as follows:

The Offerors should submit a total of 6 boxes with each box containing one complete proposal (Volume I, Volume IIA, Volume IIB and Volume III). One box of proposals should contain original signatures and 5 boxes should contain copies. Each box shall be labeled on one end (one side) indicating the RFP number, Offeror’s name, Jurisdiction E, and whether it is the original or Copy 1 of 5, Copy 2 of 5; Copy 3 of 5, etc as well as box ___ of ___.

Sample:

RFP-CMS-2011-0026

Company Name Jurisdiction E Original Signatures Box 1 of 6

RFP-CMS-2011-0026

Company Name Jurisdiction E Copy 1 of 5 Box 2 of 6

RFP-CMS-2011-0026

Company Name Jurisdiction E Copy 2 of 5 Box 3 of 6

RFP-CMS-2011-0026

Company Name Jurisdiction E Copy 3 of 5 Box 4 of 6

Each box should contain:

(a) Volume I Technical Proposal – hard copy,

(b) Volume IIA Business Proposal – hard copy (to include the Basis of Estimate on CD-ROM only)

(c) Volume IIB Business Proposal – hard copy

(d) Volume III Conflict of Interest –hard copy. Since an original and 2 copies are requested of this volume, this volume will only be in the “Originals” box and boxes for “Copy 1 of 5” and “Copy 2 of 5”.

In addition, CD_ROMs for Volumes I, IIA, IIB, and III shall be packaged with the original volumes.

The electronic copy of the business proposal templates shall be unprotected and include all formulas utilized in the formation of the spreadsheets.

3. SECTION L.9, GENERAL INSTRUCTIONS, subsection L.9.l, Page Size, Typing, Spacing, and Page Numbering, is amended as follows:

(1.) Page size shall be 8.5 by 11 inches unless otherwise indicated. Foldouts will count as two pages.

(2.) Page size for Business Proposal templates may be 11 inches by 17 inches and the type size shall not be less than 10-point Arial, no compression.

(3.) The proposal shall be page numbered.

(4.) Submit proposals, printed and copied double-sided on recycled paper to the greatest extent practicable.

(5.) Type size shall not be less than 12-point font type Times New Roman.

(6.) Each page shall be single-spaced and shall not be compressed. Each page shall have a 1” margin on all 4 sides; header and footer information may be contained within the 1” area.

(7.) Proposal text headings shall be no smaller than 12-point Times New Roman.

(8.) Table text shall be no smaller than 10-point Arial, single-line spacing, with no compression.

(9.) Proposal Graphics shall be no smaller than 10-point Arial, single-line spacing, with no compression.

(10.) The Contracting Officer, at his/her discretion, shall have the authority to waive minor deviations from the above specifications. If an Offeror would like to request a deviation from the listed specifications, then the Offeror must submit this request in writing to the Contracting Officer and Contract Specialist at least two weeks prior to the date proposals are due.

4. SECTION L.10, Proposal Assumptions, subsection L.10.f, Mandatory Workload Table, is amended as follows:

For estimating purposes, the workloads in the tables below shall be used by all Offerors in preparing their technical and business proposals. Offerors should note that the workload data for Medical Review is provided in section L.10.g., and that the Medical Review workloads are not mandatory.

In the consolidated workload chart below, the estimated base period used in calculating workload estimates are as follows: the JE Part A workload is 7 months; and the JE Part B workload is 6 months.

Workload – A/B MAC Jurisdiction E

CLIN 0002

Base Year

CLIN 0003

Option Year

CLIN 0004

Option Year

CLIN 0005

Option Year

CLIN 0006

Option Year

PM Bills/Claims Part A Workload Electronic Claims (Inclusive of Part A Pending Claims of 9,357 for the base year) 739,7203 13,241,131 13,937,614 14,754,359 15,555,520

Paper Claims 3,001 5,378 5,661 5,992 6,318

Total Part A Claims 7,400,204 13,246,509 13,943,275 14,760,351 15,561,838

PM Bills/Claims Part B Workload

Electronic Claims (Inclusive of Part B Pending Claims of 14,250 for the base year) 4,4681,331 93,434,600 98,442,694 104,398,477 110,213,472

Paper Claims 1,555,516 3,253,829 3,428,234 3,635,642 3,838,147

Total Part B Claims 46,236,847 96,688,429 101,870,928 108,034,119 114,051,619

PM Appeals Part A & B of A Workload Part A of A Redeterminations (Claims Cleared) (Inclusive of Appeals Backlog – Pending Part A Redeterminations of 677 for the base year) 1,032 637 670 709 748

Part B of A Redeterminations (Claims Cleared) 4,194 7,517 7,913 8,376 8,831

RAC Redeterminations (Claims Cleared) 731 1,309 1,378 1,459 1,538

QIC Requests Supported (Case Files Forwarded) 911 1,632 1,718 1,819 1,917

Clerical Error Reopenings 781 1,399 1,473 1,559 1,644

Non-Clerical Error Reopenings 984 1,764 1,857 1,965 2,072

Total Reopenings 1,765 3,163 3,330 3,524 3,716

Effectuations of Redeterminations (Claims) 790 1,416 1,491 1,578 1,664

Effectuations of Part A QIC Decisions (Claims) 402 720 758 802 846

Effectuations of Part A ALJ Decisions (Claims) 185 332 349 370 390

PM Appeals Part B Workload Part B Redeterminations (Claims Cleared) (Inclusive of Appeal Backlog – Pending Part B Redeterminations of 21,042 for the base year) 110,670 187,484 197,533 209,484 221,152

QIC Requests Supported (Case Files Forwarded) 11,858 24,804 26,133 27,714 29,258

Redeterminations on RAC Determinations 13,513 28,266 29,782 31,583 33,343

Clerical Error Reopenings 311,139 650,840 685,725 727,212 767,717

Non-Clerical Error Reopenings 257,294 538,207 567,055 601,362 634,858

Total Reopenings 568,433 1,189,047 1,252,780 1,328,574 1,402,575

Effectuations of Part B Redetermination Decisions (Claims) 46,041 96,309 101,471 107,610 113,604

Effectuations of Part B QIC Decisions (Claims) 11,810 24,704 26,028 27,603 29,140

Effectuations of Part B ALJ Decisions (Claims) 3,252 6,803 7,168 7,601 8,025

Part A & Part B ALJ Hearings Participation/Support

For the below ALJ Hearings Participation/Support Workload, the Offeror shall provide in the Basis of Estimate (Attachment J-07) and/or the Proposal Assumptions Template (Attachment J-25) the assumptions used to allocate the workload volume between Part A & Part B ALJ Hearings.

Combined Part A & Part B ALJ Hearings Participation/Support 60 120 120 120 120

PM Beneficiary Inquiries Part A Workload Complex Beneficiary Inquiry Responses 665 1,097 1,097 1,097 1,097

FOIA Requests 233 417 439 466 491

Complex 2nd Level Screenings 157 259 259 259 259

PM Beneficiary Inquiries Part B Workload

Note: The number provided represents the provider population for the specified Jurisdiction. It is up to the Offeror to determine the workload appropriate for each type of provider outreach and education activity. There are no minimum requirements for this function, so the Offeror must develop their own strategy for how they can best service the provider population.

Complex Beneficiary Inquiry Responses 5,172 9,962 9,962 9,962 9,962

FOIA Requests 370 774 815 865 913

Complex 2nd Level Screenings 2,725 5,248 5,248 5,248 5,248

Participating Physicians Part B Workloads

Note * Base year volume is dependent on the timing of the start of operations. The complete enrollment package is mailed in November and would be performed by the outgoing contractor or the MAC, depending on who is responsible for the workload at that time. If the MAC is responsible, the workload would be approximately the same as Option Year 1.

Enrollment Packages Mailed to Providers 31,209 60,115 60,115 60,115 60,115

PAR Enrollments 90 174 174 174 174

PAR Withdrawals 19 36 36 36 36

Combined Enrollment and Withdrawals Processed 109 210 210 210 210

Limiting Charge Reports, Violations, and Complaints Processed 2,848 5,486 5,486 5,486 5,486

PM Provider Customer Service Part A Workload

Note: The numbers provided represent the provider population for the specified Jurisdiction. It is up to the Offeror to determine the workload appropriate for each type of provider outreach and education activity. The offeror must develop its own strategy describing how it intends to service the provider population.

California Providers 2,463 2,463 2,463 2,463 2,463

Nevada Providers 132 132 132 132 132

Hawaii Providers 104 104 104 104 104

Pacific Islands of Guam, American Samoa, and Mariana 12 12 12 12 12

Out-of-Jurisdiction Providers (Mostly Chain Affiliates serviced by JE – see Section L.10.s for detailed breakout) 703 703 703 703 703

Total Providers 3,414 3,414 3,414 3,414 3,414

PM Provider Customer Service Part B Workload (Number of Providers by State)

Note: The number provided represents the provider population for the specified Jurisdiction. It is up to the Offeror to determine the workload appropriate for each type of provider outreach and education activity. The offeror must develop its own strategy describing how it intends to service the provider population.

California Providers 212,064 212,064 212,064 212,064 212,064

Nevada Providers 10,977 10,977 10,977 10,977 10,977

Hawaii Providers 7,137 7,137 7,137 7,137 7,137

Pacific Islands of Guam, American Samoa, and Mariana 281 281 281 281 281

Total Providers 230,459 230,459 230,459 230,459 230,459

Provider Reimbursement and Audit Facilities Population by Type

Note: The Hospital and Other Freestanding Facilities counts provided below are for informational purposes to be used in pricing the required workload identified at the bottom of this section.

Hospitals

Acute 335 335 335 335 335

CAH 47 47 47 47 47

LTC 14 14 14 14 14

Rehab 6 6 6 6 6

Psych 39 39 39 39 39

Child 11 11 11 11 11

Total Hospitals 452 452 452 452 452

Other Freestanding Facilities

SNF 1,373 1,373 1,373 1,373 1,373

RHC 15 15 15 15 15

CORF 26 26 26 26 26

ESRD 670 670 670 670 670

OPT 166 166 166 166 166

CMHC 19 19 19 19 19

Total Other Facilities 2,269 2,269 2,269 2,269 2,269

Total Hospitals and Other Facilities 2,721 2,721 2,721 2,721 2,721

Cost Report Acceptances 1,595 2,542 2,542 2,542 2,542

Tentative Settlements 1,135 1,135 1,135 1,135 1,135

Desk Reviews 932 1,598 1,598 1,598 1,598

Audits 83 143 143 143 143

Reopenings 323 554 554 554 554

Interim Rate Reviews 1,580 1,580 1,580 1,580 1,580

Cost Report Settlements 1,484 2,545 2,545 2,545 2,545

Cost Report Appeals 189 324 324 324 324

Wage Index Reviews 195 335 335 335 335

Provider Enrollment Part A Workload Initial Applications

Paper 341 481 481 481 481

Web 146 321 321 321 321

Changes of Information &

CHOWS

Paper 386 544 544 544 544

Web 166 363 363 363 363

Part A Revalidations (Ongoing Revalidations are included in the Part A Initial Application workload numbers above)

Special Part A Revalidation Project*** (see note following end of this workload table)

Paper 264 409 409 409 409 Web 113 274 274 274 274

Provider Enrollment Part B Workload

Initial Applications

Paper 33,179 54,710 54,710 54,710 54,710

Web 14,219 36,474 36,474 36,474 36,474

Changes of Information

Paper 14,972 24,689 24,689 24,689 24,689

Web 6,417 16,460 16,460 16,460 16,460

Reassignments

Paper 2,740 4,662 4,662 4,662 4,662

Web 1,175 3,108 3,108 3,108 3,108

Part B Revalidations (Ongoing Revalidations are included in the Part B Initial Application workload numbers above)

Special Part B Revalidation Project***(see note following the end of this workload table)

Paper 48,036 27,655 27,655 27,655 27,655 Web 20,587 18,436 18,436 18,436 18,436

PM Provider Inquiries - Part A Workload

Telephone (including IVRs) 143,474 236,586 236,586 236,586 236,586

Written Inquiries (Inclusive of Inquiries Backlog – 40 Written Correspondence ** Pending) 1,967 3,177 3,177 3,177 3,177

Congressionals - Part A 7 12 12 12 12

PM Provider Inquiries - Part B Workload

Telephone (including IVRs) 1,581,465 3,046,258 3,046,258 3,046,258 3,046,258

Written Inquiries (Inclusive of Inquiries Backlog – 1,291 Written Correspondence ** Pending) 32,521 60,156 60,156 60,156 60,156

Congressionals - Part B 351 677 677 677 677

PM Provider Inquiries - PRRS Part A Telephone Inquiries (completed calls) 171 293 293 293 293

Written Inquiries (Inclusive of Inquiries Backlog – 13 Written Correspondence ** Pending) 77 105 105 105 105

PM Provider Inquiries - PRRS Part B Telephone Inquiries (completed calls) 545 1,049 1,049 1,049 1,049

Written Inquiries (Inclusive of Inquiries Backlog – 52 Written Correspondence ** Pending) 256 393 393 393 393

Provider Oversight Part A Workload IRF Provider Billing Records Reviews (Review Estimates are based upon 6 freestanding IRFs and 83 IRF sub-units located within acute care hospitals or critical access hospitals.) 54 89 89 89 89

CORF Provider Billing Records Reviews 15 26 26 26 26

PM Non-MSP Overpayment Demand Letters Sent

Part A Demands 1,097 1,966 2,070 2,191 2,310

Part B Demands 113,012 236,398 249,068 264,137 278,850

PM Non-MSP overpayments Part A Non-MSP collections-voluntary refunds

600 1,075 1,132 1,198 1,263

Non-MSP collections-solicited checks

1,200 2,151 2,264 2,396 2,527

Non-MSP collections-debt collection and referral

40 72 76 80 85

PM Non-MSP overpayments Part B Non-MSP collections - voluntary refunds

25,379 53,087 55,933 59,317 62,620

Non-MSP collections - solicited checks

48,658 101,783 107,238 113,726 120,061

Non-MSP collections - debt collection and referral

46,105 96,441 101,611 107,758 113,760

Non-MSP collections ---- TOTAL of all above

120,142 251,311 264,782 280,801 296,441

MIP Medical Review (MR) Part A Workload – (Workload is provided in a separate chart that follows at L.10.g)

MIP Medical Review (MR) Part B Workload (Workload is provided in a separate chart that follows at L.10.g)

MIP MSP Prepay Part A Workload Claims Edits Resolved / "I" Records Resolved

11,360 21,070 22,179 23,478 24,786

Congressional Hearings and Appeal Requests

1 1 1 1 1

On-Site Hospital Reviews/Audits (see breakout below)

California 12 20 20 20 20

Nevada 4 6 6 6 6

Hawaii 2 4 4 4 4

Pacific Islands of Guam, American Samoa, and Mariana 1 1 1 1 1

Arizona (see Section L.10.s breakout of Out-of Jurisdiction Providers serviced by JE) 1 0 0 0 0

Oregon (see Section L.10.s breakout of Out-of-Jurisdiction Providers serviced by JE) 1 0 0 0 0

Total On-Site Hospital Reviews/Audits

21 31 31 31 31

Follow-up with COBC 1 1 1 1 1

MIP MSP Prepay Part B Workload Claims Edits Resolved / "I" Records Resolved

188,841 395,017 416,190 441,370 465,954

Congressional Hearings and Appeal Requests

1 1 1 1 1

Follow-up with COBC 4,638 9,703 10,223 10,841 11,445

MIP Benefit Integrity PSC/ZPIC Support - Part A PSC/ZPIC Support Requests- Non Law Enforcement

22 40 43 45 48

PSC/ZPIC Support Requests- Law Enforcement

27 49 52 55 58

# of PSC/ZPIC Support Services Provided (miscellaneous type activities such as meeting, training, or any other special requests). 15 27 28 30 32

Number of edits installed at the request of the PSC/ZPIC

6 11 12 13 13

Number of Overpayment recoupment actions received from the PSC/ZPIC

0 0 0 0 0

Effectuations of ZPIC decisions 0 0 0 0 0

MIP Benefit Integrity PSC Support - Part B PSC Support Requests-Non Law Enforcement

257 538 567 602 635

PSC Support Requests- Law Enforcement

334 698 735 780 823

# of PSC Support Services Provided For the PSC/ZPIC workload "# of PSC Support Services Provided" (miscellaneous type activities such as meetings , training , or any other special requests).

199 417 440 466 492

Number of edits installed at the request of the PSC/ZPIC

5 10 11 11 12

Number of Overpayment recoupment actions received from the PSC/ZPIC

32 67 71 75 79

Effectuations of ZPIC decisions 12,167 25,450 26,814 28,436 30,020

MIP Provider Customer Service Part A Workload

California Providers 2,463 2,463 2,463 2,463 2,463

Nevada Providers 132 132 132 132 132

Hawaii Providers 104 104 104 104 104

Pacific Islands of Guam, American Samoa, and Mariana 12 12 12 12 12

Out-of-Jurisdiction Providers (Mostly Chain Affiliates serviced by JE – see Section L.10.s for detailed breakout) 703 703 703 703 703

Total Providers 3,414 3,414 3,414 3,414 3,414

MIP Provider Customer Service Part B Workload

California Providers 212,064 212,064 212,064 212,064 212,064

Nevada Providers 10,977 10,977 10,977 10,977 10,977

Hawaii Providers 7,137 7,137 7,137 7,137 7,137

Pacific Islands of Guam, American Samoa, and Mariana 281 281 281 281 281

Total Providers 230,459 230,459 230,459 230,459 230,459

MIP MSP Postpay Part A Provider/Supplier Duplicate Primary Payments

98 182 192 203 214

General MSP Inquiries Resolved (related to debt)

2 3 4 4 4

Debt Collection and Referrals 133 247 260 276 291

General MSP Inquiries Resolved (Not related to debt)

136 252 265 281 296

MIP MSP Postpay Part B Provider/Supplier Duplicate Primary Payments (voluntary refunds, checks sent to ECRS, demands and solicited refunds)

1,885 3,944 4,155 4,407 4,652

General MSP Inquiries Resolved (related to debt)

314 656 691 733 774

Debt Collection and Referrals 7,196 15,053 15,860 16,819 17,756

General MSP Inquiries Resolved (Not related to debt)

1,893 3,961 4,173 4,425 4,672

RAC Adjustments Part A (Claims) - SLIN 000XAG

Complex 303 562 592 627 661

Automated 101,578 188,410 198,320 209,942 221,342

RAC Adjustments Part B (Claims) - SLIN 000XAH

Automated & Complex 90,087 188,443 198,544 210,556 222,284

**Pending workloads have been incorporated into the Base Period workload estimates annotated throughout the workload chart above. These pending workloads represent the carryover from the outgoing contractor.

***The Part A and Part B Special Revalidation Project estimates the remaining volume of Provider Enrollment Revalidation work required under Change Request 7588 including any subsequent instructions distributed via the CMS Technical Direction Letters. The Part A and Part B Special Revalidation Project has an initial projected completion date of March 25, 2015.

5. SECTION L.10, Proposal Assumptions, subsection L.10.g, Medical Review Workload for JE A/B MAC, is amended as follows:

g. L.10.g Medical Review Workload for JE A/B MAC (offeror may adjust these workloads based on its proposed Medical Review Strategy).

The unadjusted national overall 2011 Medicare fee-for-service payment error rate is 9.9%. This error rate is unacceptable to CMS. In the FY 2012 Online Performance

Appendix, CMS has a stated program goal to “Reduce the Percentage of Improper Payments Made Under the Medicare Fee-for-Service Program”. The FY 2012 goal is to reduce the national overall Medicare FFS payment error rate (unadjusted) to 6.2%;

moreover, CMS aims to reduce the national overall (unadjusted) Medicare FFS payment error rate to 5.8% by FY 2013, and to achieve further reductions in payment errors in FY 2014. A November 15, 2011 press release on the 2011 Medicare FFS payment error rate can be found at https://www.cms.gov/apps/media/press/factsheet.asp?Counter=4174&intNumPerPage=1 0&checkDate=&checkKey=&srchType=1&numDays=3500&srchOpt=0&srchData=&ke ywordType=All&chkNewsType=6&intPage=&showAll=&pYear=&year=&desc=&cbo Order=date

CMS has intentionally displayed the Medical Review workloads below (separate from the other Jurisdiction E workload presented in L.10.f. that are mandatory for proposal assumptions) to emphasize to Offerors the importance of this payment error rate reduction objective. The MR workloads depicted below reflect the current pattern of medical review activity in Jurisdiction E, and CMS has also used these workloads for its internal Government Cost Estimation. However, the Medical Review workloads presented below are not mandatory for proposal purposes; rather, CMS expects Offerors may derive and propose its Medical Review workloads based on its Medical Review Strategy for reducing the error rate. If the Offeror proposes workloads that differ from those in the table below, the Offeror shall provide its rationale and assumptions to support the change in workloads as part of its Medical Review Strategy (see section L.13.c, TAB C.3: Medical Review Strategy for additional instructions).

Offerors are advised that the Basis of Estimate (Attachment J-07) shall mirror their proposed workloads to support its proposed Medical Review Strategy. Further, the Offeror shall ensure that its proposed Staffing Plan under Tab C.1 of its Technical Proposal reflects its proposed Medical Review Strategy. Moreover, the Offeror shall ensure that all cost and/or level of effort is accounted for in its Business Proposal and clearly identified in its Business Proposal narrative and/or Tab F.1 Business Proposal Assumptions of Volume

IIB.

MIP Medical Review (MR) Part A Workload

Routine Manual Medical Reviews 0 0 0 0 0

Existing LCDs Revised 78 129 129 129 129 https://www.cms.gov/apps/media/press/factsheet.asp?Counter=4174&intNumPerPage=10&checkDate=&checkKey=&srchType=1&numDays=3500&srchOpt=0&srchData=&keywordType=All&chkNewsType=6&intPage=&showAll=&pYear=&year=&desc=&cboOrder=date https://www.cms.gov/apps/media/press/factsheet.asp?Counter=4174&intNumPerPage=10&checkDate=&checkKey=&srchType=1&numDays=3500&srchOpt=0&srchData=&keywordType=All&chkNewsType=6&intPage=&showAll=&pYear=&year=&desc=&cboOrder=date https://www.cms.gov/apps/media/press/factsheet.asp?Counter=4174&intNumPerPage=10&checkDate=&checkKey=&srchType=1&numDays=3500&srchOpt=0&srchData=&keywordType=All&chkNewsType=6&intPage=&showAll=&pYear=&year=&desc=&cboOrder=date https://www.cms.gov/apps/media/press/factsheet.asp?Counter=4174&intNumPerPage=10&checkDate=&checkKey=&srchType=1&numDays=3500&srchOpt=0&srchData=&keywordType=All&chkNewsType=6&intPage=&showAll=&pYear=&year=&desc=&cboOrder=date

New LCDs Developed 3 4 4 4 4

Complex Probe Reviews (Prepay and Postpay) 2,065 3,405 3,405 3,405 3,405

Prepay Complex Reviews 8,356 13,780 13,780 13,780 13,780

Postpay Complex Reviews 170 280 280 280 280

Medical Review Reopenings 678 1,118 1,118 1,118 1,118

Medical Review Claims Overturned on First Level Appeal (Note: This workload is for informational purposes only . Offerors shall not propose a level of effort for this category because the Appeals Redetermination Workload Category captures the level of effort for Medical Review Claims Overturned on First Level Appeals.)

439 724 724 724 724

Medical Review Data Requests (includes internal (e.g. MAC appeals and external e.g. OIG data requests) 245 420 420 420 420

Medical Review Limited Education 0 0 0 0 0

MIP Medical Review (MR) Part B Workload

Routine Manual Medical Reviews 0 0 0 0 0

Existing LCDs Revised 70 139 139 139 139

New LCDs Developed 2 4 4 4 4

Complex Probe Reviews (Prepay and Postpay) 1,799 3,465 3,465 3,465 3,465

Prepay Complex Reviews 36,091 69,520 69,520 69,520 69,520

Postpay Complex Reviews 736 1,418 1,418 1,418 1,418

Medical Review Reopenings 7,100 13,676 13,676 13,676 13,676

Medical Review Claims Overturned on First Level Appeal (Note: This workload is for informational

15,260 29,394 29,394 29,394 29,394 purposes only . Offerors shall not propose a level of effort for this category because the Appeals Redetermination Workload Category captures the level of effort for Medical Review Claims Overturned on First Level Appeals.)

Medical Review Data Requests 245 420 420 420 420

Medical Review Limited Education 0 0 0 0 0

6. SECTION L.10, Proposal Assumptions, subsection L.10.h, Change Requests and

Technical Direction Letters (TDLs), is amended as follows:

h. Change Requests and Technical Direction Letters (TDLs) (mandatory workloads).

In Fiscal Year (FY) 2010, CMS issued approximately 525 draft change requests (CRs) to Medicare Contractors, Shared System Maintainers (SSMs), and the Common Working File (CWF) Maintenance Contractor for review and comment. (This is otherwise known as the Point of Contact (POC) Review period, which is described in detail in section C.4, Participation in Change Management Process, of the SOW.) Approximately 431of the draft CRs were issued in final for implementation. Approximately 68 percent of those issued CRs resulted in changes to the Shared Systems and the Common Working File.

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