AB_MAC_JJ_Amendment_00001.pdf

RFP-CMS-2013-0026 A/B MAC Jurisdiction J 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 is hereby deleted and a revised J-01 Statement of Work dated January 2, 2013 is provided as an attachment hereto.

II. PART III – LIST OF DOCUMENTS, EXHIBITS AND OTHER ATTACHMENTS

A. SECTION J – LIST OF ATTACHMENTS, is amended as follows:

ATTACHMENT J-01, Statement of Work (SOW), is deleted and replaced with J-01 Statement of Work, dated January 2, 2013, provided as an attachment hereto.

ATTACHMENT J-02, Deliverable Schedule, is deleted and replaced with J-02 Deliverable Schedule, provided as an attachment hereto.

ATTACHMENT J-07, Basis of Estimate, is deleted and replaced with J-07 Basis of Estimate, provided as an attachment hereto.

ATTACHMENT J-09, Cost Proposal Instructions, is deleted and replaced with J-09 Cost Proposal Instructions, provided as an attachment hereto.

ATTACHMENT J-12, CLIN 002 Cost Proposal Template, is deleted and replaced with J-12 CLIN 002 Cost Proposal Template, provided as an attachment hereto.

ATTACHMENT J-13, CLIN 003 Cost Proposal Template, is deleted and replaced with J-13 CLIN 003 Cost Proposal Template, provided as an attachment hereto.

ATTACHMENT J-14, CLIN 004 Cost Proposal Template, is deleted and replaced with J-14 CLIN 004 Cost Proposal Template, provided as an attachment hereto.

ATTACHMENT J-15, CLIN 005 Cost Proposal Template, is deleted and replaced with J-15 CLIN 005 Cost Proposal Template, provided as an attachment hereto.

ATTACHMENT J-16, CLIN 006 Cost Proposal Template, is deleted and replaced with J-16 CLIN 006 Cost Proposal Template, provided as an attachment hereto.

ATTACHMENT J-29, Service Center Matrix, is deleted and replaced with J- 29 Service Center Matrix, provided as an attachment hereto.

III. PART IV – REPRESENTATIONS AND INSTRUCTIONS

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

is amended as follows:

1. SUBSECTION L.9, GENERAL INSTRUCTIONS, is amended as follows:

g. Binding and Labeling

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 6), 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 7 boxes. One box of proposals should contain original signatures and 6 boxes should contain copies.

Each box should be labeled according to content (e.g. Original, Copy 1 of 6, Copy 2 of 6, etc).

Sample:

RFP-CMS-2013-0017

Company Name Jurisdiction J Original Signatures

RFP-CMS-2013-0017

Company Name Jurisdiction J Copy 1 of 6

RFP-CMS-2013-0017

Company Name Jurisdiction J Copy 2 of 6

RFP-CMS-2013-0017

Company Name Jurisdiction J Copy 3 of 6

Each box should be labeled on one end and one side with the RFP number, Offeror’s name, Jurisdiction J, and box ___ of ___.

Each box should contain:

(a) Volume I Technical Proposal – hard copy,

(b) Volume IIA Business Proposal – hard copy

(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 2” and “Copy 2 of 2”.

In addition, the box with ORIGINALS should also contain the master and back-up CD-ROMs for each of Volumes I, IIA, IIB, and III in the “ORIGINALS” box.

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

2. SUBSECTION L.10, PROPOSAL INSTRUCTIONS, is hereby deleted in its entirety and replaced with the following:

Offerors shall use the following assumptions when developing their proposal:

a. Implementation Cutover Date

The Offeror shall use the Implementation cutover date developed by CMS (see table below) when developing its proposed CLIN 0001 costs associated with its Jurisdiction Implementation Project Plan. Completion of the movement of the Jurisdiction to the incoming MAC shall occur within six (6) months of award.

At the implementation cutover date the outgoing MAC ceases Medicare operations and the incoming MAC begins to perform Medicare business functions for that jurisdiction.

The following table considers each individual Customer Information Control System (CICS) region as an individual “segment”.

Outgoing Contractor

State(s) Claim Type Enterprise Data Center

Implementation Cutover Date

Cahaba AL A CDS February 18, Cahaba GA A CDS February 18, Cahaba TN A CDS February 18, Cahaba AL B CDS March 17, 2014

Cahaba GA B CDS March 17, 2014

Cahaba TN B CDS March 17, 2014

b. All workloads have been converted to the Healthcare Integrated General Ledger

Accounting System (HIGLAS).

c. It is anticipated that the MAC contract award for Jurisdiction J shall be made on or about September 16, 2013.

d. Joint Operating Agreements between functional contractors impacting the MACs shall be executed prior to the operational start date. The operational start date is defined as the date that the MAC assumes all Medicare functions from an outgoing contract and is capable of processing Medicare claims for that jurisdiction. Please refer to the implementation cutover dates in the chart above for the operational start dates. The dates are depicted in the timeline below:

Implementation and Base Periods – 9/16/2013 – 9/15/2014

9/16/2013 2/18/2014 1/6/2014 3/17/2014 9/15/2014

Overlapping Implementation and Base Periods are shown below:

Implementation of Part A starts on 9/16/2013 and ends on 2/17/2014 Implementation of Part B starts on 9/16/2013 and ends on 3/16/2014 Base Period for Part A starts on 2/18/2014 and ends on 9/15/2014 Base Period for Part B starts on 3/17/2014 and ends on 9/15/2014

Contract Award -

Implementation

Part A Cutover

Current JJ Contract

Ends

End of Base Year

CLIN 0001 - Implementation

Part B Cutover

TABLE OF ESTIMATED DATES FOR CLINs 0001 - 0007 CLIN Workload Timeframe CLIN 0001 – IMPLEMENTATION Part A

Part B 9/16/2013 – 2/17/2014 9/16/2013 – 3/16/2014

CLIN 0002 – BASE Part A Part B

2/18/2014 – 9/15/2014 3/17/2014 – 9/15/2014

CLIN 0003 - OPTION 1 9/16/2014 – 9/15/2015

CLIN 0004 - OPTION 2 9/16/2015 – 9/15/2016

CLIN 0005 - OPTION 3 9/16/2016 – 9/15/2017

CLIN 0006 - OPTION 4 9/16/2017 – 9/15/2018

CLIN 0007 – CLOSE OUT 3/16/2018 –9/15/2018

e. 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 given at section L.10.f.

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

Workload – A/B MAC Jurisdiction J

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

(*Base Period includes 6,359 Part A Pending)

*8,740,272 16,080,381 17,141,686 17,947,345 18,575,502

Paper Claims 7,554 13,908 14,825 15,522 16,066

CLIN 0002 – Base Period

9/16/2013 Start of CLIN 0001

Part A Cutover Part B Cutover End of CLIN 0001

2/18/2014 Start of CLIN 0002

Start of Part A Base Period

9/15/2014 End of CLIN 0002

3/17/2014 Start of Part B Base Period

Total Part A Claims 8,747,826 16,094,288 17,156,511 17,962,867 18,591,568

PM Bills/Claims Part B Workload Electronic Claims

(*Base Period includes 15,622 Part B Pending)

*37,335,015 80,162,055 85,693,237 89,720,819 92,771,327

Paper Claims 758,395 1,629,033 1,741,436 1,823,283 1,885,275

Total Part B Claims 38,093,410 81,791,088 87,434,673 91,544,103 94,656,602

PM Appeals Part A & B of A Workload Part A of A Redeterminations (Claims Cleared) (*Base Period includes 1656 Part A of A Pending)

*13,525 21,863 21,863 21,863 22,628

Part B of A Redeterminations (Claims Cleared) (*Base Period includes 4656 Part B of A Pending)

*16,395 21,613 23,040 24,123 24,967

RAC Redeterminations (Claims Cleared)

11,277 20,763 22,133 23,174 23,985

QIC Requests Supported (Case Files Forwarded)

6,646 12,236 13,043 13,656 14,134

Clerical Error Reopenings 1,119 2,061 2,197 2,300 2,381

Non-Clerical Error Reopenings 2,483 4,572 4,874 5,103 5,282

Total Reopenings 3,602 6,633 7,071 7,403 7,663

Effectuations of Redeterminations (Claims)

3,478 6,404 6,826 7,147 7,397

Effectuations of Part A QIC Decisions (Claims)

213 392 417 437 452

Effectuations of Part A ALJ Decisions (Claims)

494 910 970 1,016 1,052

PM Appeals Part B Workload Part B Redeterminations (Claims Cleared) (*Base Period includes 16,276 Part B Redeterminations Pending)

*64,536 55,252 59,064 61,840 63,943

QIC Requests Supported (Case Files Forwarded)

3,997 4,577 4,892 5,122 5,297

Redeterminations on RAC Determinations

6,876 8500 8500 8500 8500

Clerical Error Reopenings 100,544 115,111 123,054 128,837 133,218

Non-Clerical Error Reopenings 3,427 3,924 4,194 4,392 4,541

Total Reopenings 103,971 119,035 127,248 133,229 137,759

Effectuations of Part B Redetermination Decisions (Claims)

15,547 17,800 19,028 19,922 20,600

Effectuations of Part B QIC Decisions (Claims)

1,086 1,243 1,329 1,391 1,438

Effectuations of Part B ALJ Decisions (Claims)

58 66 71 74 76

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-24) the assumptions used to allocate the workload volume between Part A & Part B ALJ Hearings.

Combined Part A & Part B ALJ Hearings Participation/Support 88 142 142 142 142

PM Beneficiary Inquiries Part A Workload

Complex Beneficiary Inquiry Responses

318 586 625 654 677

Complex 2nd Level Screenings 194 357 380 398 412

PM Beneficiary Inquiries Part B Workload

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

Complex Beneficiary Inquiry Responses

1,737 3,731 3,989 4,176 4,318

Complex 2nd Level Screenings 1,124 2,415 2,582 2,703 2,795

FOIA Requests

FOIA Requests Part A & Part B 661 1,216 1,298 1,359 1,406

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

12,259 27,675 29,585 30,975 32,029

PAR Enrollments 2,662 6,009 6,424 6,726 6,954

PAR Withdrawals 35 69 69 69 69

Combined Enrollment and Withdrawals Processed

3,580 7,689 8,219 8,606 8,898

Limiting Charge Reports, Violations, and Complaints Processed

1,929 3,858 3,858 3,858 3,858

PM Provider Customer Service Part A Workload

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

See Section L.10.h for the breakout of out-of-jurisdiction providers serviced by JJ.

Alabama Providers 419 419 419 419 419

Georgia Providers 718 718 718 718 718

Tennessee Providers 691 691 691 691 691

Out-of-Jurisdiction Providers 2,171 2,171 2,171 2,171 2,171

Total Providers 3,999 3,999 3,999 3,999 3,999

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 bidder to determine the workload appropriate for each type of provider outreach and education activity. There are no minimum requirements for this function, so the bidder must develop their own strategy for how they can best service the provider population.

See Section L.10.h for the breakout of out-of-jurisdiction providers serviced by JJ.

Alabama Providers 20,801 20,801 20,801 20,801 20,801

Georgia Providers 41,867 41,867 41,867 41,867 41,867

Tennessee Providers 32,774 32,774 32,774 32,774 32,774

Out-of-Jurisdiction Providers 0 0 0 0 0

Total Providers 95,442 95,442 95,442 95,442 95,442

CMS policy on where providers are assigned is changing. “Provider nomination” (the ability of a provider to select the contractor of its choice) has been repealed. National and regional contractors for specific provider types such as FQHCs, RHCs, and ESRD facilities will no longer exist in the MAC environment. Providers will generally be assigned to the MAC that covers the state where the provider is located. There are exceptions.

These workload numbers are estimates for the purposes of creating a sample workload on which to bid.

Workload will be shifted in a phased fashion as CMS systems that support the claims processing, provider enrollment, and cost report auditing functions are capable of accomplishing the workload transitions. The base year provider workload will be established during post award negotiations. Subsequent contract modification processes will address shifts in provider counts as additional workload transition takes place in the four contract renewal periods.

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 252 252 252 252 252

CAH

49 49 49 49 49

LTC

20 20 20 20 20

Rehab 72 72 72 72 72

Psych 30 30 30 30 30

Child 6 6 6 6 6

Total Hospitals 429 429 429 429 429

Other Freestanding Facilities

SNF

616 616 616 616 616

RHC

1,308 1,308 1,308 1,308 1,308

CORF

9 9 9 9 9

ESRD

1,191 1,191 1,191 1,191 1,191

OPT

341 341 341 341 341

FQHC

79 79 79 79 79

CMHC

67 67 67 67 67

Total Other Facilities 3,611 3,611 3,611 3,611 3,611

Total Hospitals and Other Facilities

4040 4040 4040 4040 4040

Receipt & Acceptance of Medicare Cost Reports (Cost Report Acceptances)

2,088 3,580 3,580 3,580 3,580

Tentative Settlements 1,892 3,244 3,244 3,244 3,244

Desk Reviews 1,807 3,098 3,098 3,098 3,098

Audits 25 42 42 42 42

Reopenings 88 150 150 150 150

Interim Rate Reviews 3,441 5,898 5,898 5,898 5,898

Cost Report Settlements 2,177 3,732 3,732 3,732 3,732

Cost Report Appeals 33 57 57 57 57

Wage Index Reviews 151 258 258 258 258

Provider Enrollment Part A Workload Initial Applications

Paper 364 670 714 748 774

Web 53 98 105 110 114

Changes of Information &

CHOWS

Paper 947 1,743 1,858 1,945 2,013

Web 52 96 102 107 111

***Revalidations

Paper

616 1,058 1,128 1,181 1,222

Web 105 180 192 201 208

***Revalidations (Paper & Web) capture both ongoing and special revalidation project estimated workloads.

Provider Enrollment Part B Workload

Initial Applications

Paper 11,824 25,397 27,150 28,426 29,392

Web 2,710 5,833 6,236 6,529 6,751

Changes of Information &

CHOWS

17,126 36,786 39,325 41,173 42,573

Web 2,612 5,611 5,998 6,280 6,493

***Revalidations

7,214 14,305 15,292 16,010 16,555

Web 2,145 4,254 4,547 4,761 4,923

***Revalidations (Paper & Web) captures both ongoing and special revalidation project estimated workloads.

PM Provider Inquiries - Part A Workload Telephone (Including IVR)

(*First two months of Base Year include an increase in workload of 5250 Part A Telephone Inquiries) *126,291 207,499 207,499 207,499 207,499

Written Inquiries (*Base Year includes 1 Part A Written Inquiry Pending) *846 1,449 1,449 1,449 1,449

Congressional - Part A 24 41 41 41 41

PM Provider Inquiries - Part B Workload Telephone (Including IVR)

(*First two months of Base Year include an increase in workload of 36,652 Part B Telephone Inquiries) *730,975 1,388,645 1,388,645 1,388,645 1,388,645

Written Inquiries (*Base Year includes 1 Part B Written Inquiry Pending)

*1,621 3,240 3,240 3,240 3,240

Congressional - Part B 183 366 366 366 366

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

1 1 1 1 1

Written Inquiries (*Base Year includes 1 PRRS Part A Written Inquiry Pending)

*136 232 232 232 232

PM Provider Inquiries - PRRS Part B Telephone Inquiries (completed calls)

1 1 1 1 1

Written Inquiries (*Base Year includes 1 PRRS Part B Written Inquiry Pending)

*11 20 20 20 20

Provider Oversight Part A Workload IRF Provider Billing Records Reviews

68 116 116 116 116

CORF Provider Billing Records Reviews

5 9 9 9 9

PM Non-MSP Overpayment Demand Letters Sent

Part A Demands 13,130 24,175 25,770 26,982 27,926

Part B Demands 117,211 134,193 143,452 150,195 155,301

PM Non-MSP overpayments Part A Non-MSP Collections - debt collections and referral 409,594 754,120 803,892 841,675 871,134

Non-MSP Collections - voluntary refunds 597 1,024 1,024 1,024 1,024

Non-MSP - solicited checks 3,046 5,222 5,222 5,222 5,222

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

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

15,601 31,201 31,201 31,201 31,201

Non-MSP collections - solicited checks

10,589 21,177 21,177 21,177 21,177

Non-MSP collections - debt collection and referral

1,411 3,031 3,240 3,392 3,508

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

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

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

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

71,418 131,492 140,170 146,758 151,894

Congressional Hearings and Appeal Requests

1 1 1 1 1

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

Alabama Providers 12 20 20 20 20

Georgia Providers 12 20 20 20 20

Tennessee Providers 12 20 20 20 20

Out-of-Jurisdiction Providers **See breakout in Section L.10.g 0 0 0 0 0

Total On-Site Hospital Reviews/Audits

35 60 60 60 60

Follow-up with COBC 43 73 73 73 73

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

217,581 467,365 499,613 523,094 540,880

Congressional Hearings and Appeal Requests

1 1 1 1 1

Follow-up with COBC 3,945 7,890 7,890 7,890 7,890

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

64 222 237 248 257

PSC/ZPIC Support Requests- Law Enforcement

92 61 65 68 71

Number of PSC/ZPIC Support Services Provided (miscellaneous type activities such as meeting, training, or any other special requests).

42 285 303 318 329

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

1 1 1 1 1

Number of Overpayment recoupment actions received from the PSC/ZPIC

39 53 56 59 61

Effectuations of ZPIC decisions 1 1 1 1 1

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

276 1,213 1,297 1,358 1,404

PSC/ZPIC Support Requests- Law Enforcement

316 310 332 347 359

Number of PSC/ZPIC Support Services Provided (miscellaneous type activities such as meetings, training, or any other special requests).

177 1,543 1,649 1,727 1,785

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

31 58 58 58 58

Number of Overpayment recoupment actions received from the PSC/ZPIC 319 617 660 691 714

Effectuations of ZPIC decisions 35 102 109 114 118

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

See Section L.10.h for a breakout of out-of-jurisdiction providers serviced by JJ.

Alabama Providers 419 419 419 419 419

Georgia Providers 718 718 718 718 718

Tennessee Providers 691 691 691 691 691

Out-of-jurisdiction Providers 2,171 2,171 2,171 2,171 2,171

Total Providers 3,999 3,999 3,999 3,999 3,999

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

See Section L.10.h for a breakout of out-of-jurisdiction providers serviced by JJ.

Alabama Providers 20,801 20,801 20,801 20,801 20,801

Georgia Providers 41,867 41,867 41,867 41,867 41,867

Tennessee Providers 32,774 32,774 32,774 32,774 32,774

Out-of-jurisdiction Providers 0 0 0 0 0

Total Providers 95,442 95,442 95,442 95,442 95,442

MIP MSP Postpay Part A Provider/Supplier Duplicate Primary Payments

309 568 606 634 656

General MSP Inquiries Resolved (related to debt)

107 197 210 220 228

Debt Collection and Referrals 5 8 9 9 10

General MSP Inquiries Resolved (Not related to debt)

1,245 2,292 2,443 2,558 2,647

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

8,957 19,239 20,567 21,533 22,265

General MSP Inquiries Resolved (related to debt)

12,093 25,976 27,769 29,074 30,062

Debt Collection and Referrals 139 300 320 335 347

General MSP Inquiries Resolved (Not related to debt)

12,887 27,681 29,591 30,982 32,035

RAC Adjustments Part A (Claims) - SLIN 000XAG

Complex 27,440 47,040 47,040 47,040 47,040

Automated 21,560 36,960 36,960 36,960 36,960

RAC Adjustments Part B (Claims) - SLIN 000XAH

Automated & Complex 78,000 156,000 156,000 156,000 156,000

***The Part A and Part B Special Revalidation Project estimates the remaining volume of Provider Enrollment Revalidation work required under Change Request 7350 including any subsequent instructions distributed via the CMS Technical Direction Letters. The Part A and Part B Special Revalidation Project has a project completion date of March 24, 2013.

f. Medical Review Workload for JJ A/B MAC.

One of CMS’s most critical operational objectives is to reduce the Medicare payment error rate (as measured by CERT). The national Medicare fee-for-service payment error rate is estimated at 10.5%. This error rate is unacceptable to CMS.

CMS has intentionally displayed the Medical Review (MR) workloads below (from the other Jurisdiction J workload presented in L.10.e. that are mandatory for bidding assumptions) to emphasize to Offerors the importance of this payment error rate reduction objective. The MR workloads depicted below reflect the current pattern of MR activity in Jurisdiction J and CMS has also used these workloads for its internal Government Cost Estimation. However, the MR workloads presented below are not mandatory for bidding purposes; rather, Offerors may propose any MR workloads that are consistent with its MR strategy for reducing the error rate.

Offerors are advised that the Basis of Estimate (Attachment J-07) shall mirror their proposed workloads to support its MR strategy. Offerors are also advised that staffing plan changes that result from its MR strategy must be included in its overall staffing plan; moreover, any associated cost must be clearly identified within its Business Proposal narrative, and/or Tab F.1 Business Proposal Assumptions of Volume IIB. MR strategy must also be consistent with MR Strategy activities included in L.13.c, Tab C.4.

MIP Medical Review (MR) Part A Workload Routine Manual Medical Reviews

0 0 0 0 0

Existing LCDs Revised 9 15 15 15 15

New LCDs Developed 0 0 0 0 0

Complex Probe Reviews (Prepay and Postpay)

2,096 3,593 3,593 3,593 3,593

Prepay Complex Reviews 11,275 19,328 19,328 19,328 19,328

Postpay Complex Reviews 0 0 0 0 0

Medical Review Reopenings 1,035 1,774 1,774 1,774 1,774

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.)

216 370 370 370 370

Medical Review Data Requests 2,102 3,603 3,603 3,603 3,603

Medical Review Limited Education

254 435 435 435 435

MIP Medical Review (MR) Part B Workload Routine Manual Medical Reviews

1,250 2,500 2,500 2,500 2,500

Existing LCDs Revised 30 60 60 60 60

New LCDs Developed 4 8 8 8 8

Complex Probe Reviews (Prepay and Postpay)

11,151 22,302 22,302 22,302 22,302

Prepay Complex Reviews 18,530 37,060 37,060 37,060 37,060

Postpay Complex Reviews 44 88 88 88 88

Medical Review Reopenings 5,000 10,000 10,000 10,000 10,000

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.)

5,360 10,720 10,720 10,720 10,720

Medical Review Data Requests 2,250 4,500 4,500 4,500 4,500

Medical Review Limited Education

807 1,614 1,614 1,614 1,614

g. Jurisdiction J Jurisdiction-Specific Requirements

For A/B MAC Jurisdiction J, the offeror shall propose its technical approach to meeting the jurisdiction-specific requirements listed below and detailed in the SOW. For proposal purposes offerors shall place all cost associated with the jurisdiction specific requirements below within the associated WBS in the cost templates. For example, all costs associated with Limited Purpose Insurance Companies shall be placed in C.7.14. Upon contract award the awardee shall separate costs into the appropriate SOW functions.

Limited Purpose Insurance Companies

Number of Entities 44

Number of Desk Reviews (annual) 30

Number of Final Settlements (annual) 30

Independent Organ Procurement Organizations

Number of Entities 51

Number of Desk Reviews (annual) 25

Number of Final Settlements (annual) 30

Religious Non-medical Health Care Institutions

Number of Entities 16

Number of Desk Reviews (annual) 10

Number of Final Settlements (annual) 20

Claims Volume (annual) 869

Histocompatibility Labs

Number of Entities 16

Number of Desk Reviews (annual) 40

Number of Final Settlements (annual) 45

h. Jurisdiction J Out-of-Jurisdiction Provider Facilities Table

For A/B MAC Jurisdiction J, the Offeror shall assume a total of 2,171 out-of-jurisdiction providers which are primarily chain affiliated providers. The breakout of this total by state and medical facility is shown in the table below.

Jurisdiction 10-- Out of State Providers

States Acute LTC Rehab SNF RHC ESRD OPT TOTAL

Alaska

2 4

Arizona

4 19

13 6 42

Arkansas

1 2

1 2 6

California

1 13 136 87 11 248

Colorado

2 13 39

Connecticut

14 7 21

Florida

1 9 24 106 78 19 237

Idaho

9 20

1 30

Illinois

1 3 124 15 11 154

Indiana

1 18 38 6 7 70

Iowa

51 1

Kansas

12 45 4 2 63

Kentucky

1 8 90 22 3 124

Louisiana

25 1 28

Maine

2 4 6

Massachusetts

14 3 19

Michigan

4 55 32 1 92

Minnesota

2 16

Mississippi 5

1 71 4 2 83

Missouri

1 23 148 55 6 233

Nebraska

Nevada

4 8 15

New Hampshire

1 3

1 2 7

New Mexico

1 1

8 2 12

New York

North Carolina

10 54 19 6 89

Ohio

4 8 39 6 57

Oklahoma

5 8 13

Rhode Island

2 1 5

South Carolina

5 18 77 41 4 145

Texas 1

8 8

35 18 70

Utah

1 3

2 6 Virginia -excluding the counties of Fairfax and Arlington, and the City of Arlington 2

4 7

29 8 50

Washington

West Virginia

Wisconsin

1 15 24

Wyoming

TOTAL 8 3 45 245 1,107 595 168 2,171

i. Electronic Data Interface (EDI) Inquiries

For proposal purposes only, Offerors shall assume the following estimated workload for (EDI) Inquiries.

EDI Inquiries

Period of Performance # of Business Days Average Daily Call Volume

2/18/2014 – 6/17/2014 83 days 1150

6/14/2014 – 9/15/2014 64 days 500

9/16/2014 – 9/15/2015 250 days 400

9/16/2015 – 9/15/2016 250 days 400

9/16/2016 – 9/15/2017 250 days 400

9/16/2017 – 9/15/2018 250 days 400

j. Change Requests and Technical Direction Letters (TDLs).

In Fiscal Year (FY) 2010, the 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.

(1) DRAFT CR: For proposal purposes only, Offerors shall assume that the estimated workload associated with reviewing, commenting, and submitting a Level of Effort (LOE) assessment on draft CRs is as follows:

DRAFT CR

estimated workload

Period of Performance % increase from prior year

CRs

Base Year (500 annually, adjusted for 6 months)

Option Year 1 5% 525 Option Year 2 5% 551 Option Year 3 5% 579 Option Year 4 5% 608

(2) FINALIZED CR: For proposal purposes only, Offerors shall use the estimated workload associated with implementing finalized issued CRs as provided in the two charts below. The first chart indicates workload that will require shared system changes and the second chart indicates workload that will not require shared system changes.

Estimated workload for CRs issued in final that will require Part A and/or Part B shared system changes is provided in the chart below.

Finalized issued CRs requiring shared system changes

Period of Performance % increase from prior year

CRs

Base Year (308 annually, Option Year 1 5% 323 Option Year 2 5% 340 Option Year 3 5% 357 Option Year 4 5% 374

Estimated workload for CRs that will not require Part A and/or Part B shared system changes, but will have MAC impact are in the table below.

Finalized issued CRs NOT requiring shared system changes

Period of Performance % increase from prior year CRs

Base Year (132 annually, Option Year 1 5% 139 Option Year 2 5% 146 Option Year 3 5% 153 Option Year 4 5% 160

(3) TECHNICAL DIRECTION LETTER: For proposal purposes only, Offerors shall assume the workload provided in the chart below for Technical Direction Letters that CMS will issue to MACs.

Technical Direction Letters

Period of Performance CRs

Base Year (500 annually, adjusted for 6 months) 250 Option Year 1 500 Option Year 2 500 Option Year 3 500 Option Year 4 500

k. Manual References in the Statement of Work.

The Offeror shall prepare their proposal based upon the version of the Manuals (both the Internet-Only Manuals and Paper-Based Manuals) as of the date of the RFP release. The Statement of Work (Attachment J-01) has precedence over the Internet-Only Manuals, which in turn has precedence over the Paper Based Manuals. The Offeror shall not respond to manual changes issued after the RFP release date unless otherwise instructed by CMS.

l. Records Retention.

For A/B MAC Jurisdiction J, the Offeror shall assume a total of 324,858 cubic feet of file storage for Medicare records. The breakout of this total by locale is provided in the chart below. The NARA compliance will be enforced on this procurement. Offerors are to assume that 27,721 cubic feet of storage is already located in a NARA compliant facility.

Offerors are required to identify and/or negotiate rates with a NARA compliant facility.

For proposal purposes, if an Offeror must relocate files they shall assume the file locations provided in the chart below. For proposal purposes, the costs associated with the Medicare files and data transfer will be considered Implementation Costs. For proposal purposes only, please assume a cost of $300,000 in the permanent withdrawal fees for these records. Offerors are to assume the cost of file storage in the operational periods and record costs in the operational cost CLINS (Base and Option Years 1 through 4).

Offeror shall include with this proposal any proposed or negotiated agreement currently reached with a business partner for records retention.

Jurisdiction JJ Location

NARA

Compliant

Facility

# of Cubic Feet

(1 cubic foot = 1 box) Iron Mountain no 254876.71 Data Savers yes 27720.6 Atlantic no 1849.5 Livingston no 0 National Records Management no 36317 Cahaba (onsite) 4094.18

JJ Total Cubic Feet of Boxes 324,857.99

m. Manage Paper Bills/Claims.

In the management of paper bills and claims addressed in Attachment J-01 – Statement of Work, section, C.5.8 the images from the outgoing contractor will be transferred to the incoming contractor. For proposal purposes, the Offeror shall assume that the formats of these images are compatible with their systems. Additional information regarding the images from the outgoing contractor will be provided after contract award and during the implementation period.

n. Electronic Document and Data Retrieval.

For obtaining, reading and storing historical electronic files addressed in Attachment J-01

– Statement of Work, section C.5.1., for proposal purposes, Offerors shall assume that historical electronic file formats are compatible with their systems. Additional information will be provided after contract award and during the implementation period.

o. Cost Proposal Templates.

Offerors may adjust formulas within the CLIN templates to ensure accuracy in its cost proposal.

p. Participation in Conferences.

In accordance with section C.5.4.7. of Statement of Work (Attachment J-01), the contractor shall participate in conferences. For proposal purposes, Offerors should plan for 12 conferences annually (6 in Baltimore, Maryland and 6 in Denver, Colorado), 4 attendees at each conference, and 2 overnights at each conference.

In addition to the 12 conferences, the Offeror should plan to attend two Security Best Practices conferences annually (1 in Baltimore, Maryland and 1 in Denver, Colorado), with 3 overnights at each conference.

Additionally, the Offeror should propose to the following conferences and workgroups in the Provider Customer Service (PCSP) functional area: (a) Provider Customer Service Program Conference once every two years (up to 5 contractor staff may attend). Type of staff requested (representatives from provider outreach and education, provider inquiries, webmaster, customer service representative, etc.), (b) Monthly Provider Customer Service Program User Group teleconference. Provider inquiry and provider outreach and education representatives from the contractors attend, and (c) Periodic workgroups (about two per year) with contractor representatives to address PCSP issues. The workgroups always meet by teleconference, usually on a weekly or monthly basis.

In addition to the proposal assumptions provided above for section C.5.4.7, Offerors shall propose any travel required to perform other requirements in the statement of work.

Additional travel may include, but is not limited to, the following sections of the SOW:

C.5.6 Local Coverage Determinations

C.5.11.3 Cost Reporting and Reimbursement Payment Policy

C.5.12 Medical Review

C.5.14.5 Medicare Secondary Payer Hospital Audits

C.5.23.1

Post-award Meeting

q. Provider Outreach and Education - Direct mailings.

For proposal purposes, Offerors should plan for two (2) direct mailings a year to all enrolled providers in accordance IOM Pub 100-9, Chapter 6.

r. Health Information Technology for Economic and Clinical Health Act (HITECH).

The Jurisdiction J A/B MAC shall perform the activities required by section C.5.11.3.6.

of the SOW. For proposal purposes, Offerors shall assume that the JJ MAC has successfully accomplished the initial data load activities mentioned in this SOW provision (i.e., the data load activities required to be accomplished by March 31, 2011).

For proposal purposes, Offerors shall only include costs associated with periodic data maintenance activities as required by the SOW provision. CMS may define further HITECH requirements and add them to the MAC SOW as a post-award contract modification. CMS Regulations pertaining to the HITECH program (CMS-0033-F) are located at: http://edocket.access.gpo.gov/2010/pdf/2010-17207.pdf.

s. Postage and Printing Costs.

For proposal purposes, Offerors shall assume a three (3) percent escalation on postage costs for each contract year. Offerors shall also clearly delineate their proposed assumptions for all proposed print/mail costs under Tab F.1 of its Business Proposal. At a minimum, Offerors shall identify all categories of items to be mailed on this contract (e.g., MSNs, SPRs, etc.), the proposed workload for each category, how the Offeror estimated the workload for each category, and the proposed unit cost for each workload category. The Offeror shall include, as a separate workload category, its assumptions and cost estimates for revalidation letters mailed to providers, both as a result of the Provider Enrollment Revalidation Project (see workload under section L.10.e) in the Base Year and the ongoing revalidations included in the Initial Applications workloads (see section L.10.e) for the Option Years. The Offeror shall also separate costs for printing and postage services.

t. Banking.

CMS now provides banking services to MACs through standard commercial banking contracts. Beginning February 2012, CMS no longer provides lockbox services as part of these standard commercial banking contracts. Therefore, Offerors shall include as part of this proposal any costs associated with creating their own subcontract for lockbox services, or switching their banking procedures such that lockboxes are no longer needed for MAC functions. For example, the MAC Contractor could coordinate with CMS and its assigned Bank (currently either US Bank or JP Morgan Chase) to open a lockbox and link that lockbox with the MAC’s Medicare Bank Account. In this example, the MAC Contractor would have to form a separate subcontract with the Bank to pay for the use of http://edocket.access.gpo.gov/2010/pdf/2010-17207.pdf the lockbox, which should be billed as an expense to the MAC Contract for which it has been established.

u. Freedom of Information Act (FOIA) Requests.

Offerors should note that FOIA workload has been included in the workload assumption chart.

v. Award Fee Plan.

The JJ incumbent shall not propose an award fee for the CLIN 0001 implementation period.

w. Statement on Standards for Attestation Engagements (SSAE) 16, Reporting on

Controls at a Service Organization.

Offerors are advised that all MACs will be required to follow the SSAE No. 16 auditing procedures as described in the Statement of Work (SOW), Attachment J-01, section C.5.4.10.4. Formerly, MACs were required to follow the SAS 70 procedures. As part of the requirement, the Contractor shall update the information that is shown in Section II of the SSAE 16 report, Description of Internal Control Structure Control Environment and Applications. With the new SSAE 16 procedures, the Contractor shall prepare a written assertion attesting to the fair presentation and design of controls. Under SAS 70, it was the auditors who reported directly on the controls. Contractors will also be required to internally track and correct Section III findings. Contractors are required to prepare and maintain documentation to support the status and corrective actions taken on Section III findings. The Offeror is advised to clearly identify where inclusion of SSAE 16 support costs are in the Business Proposal Narrative, and/or Tab F.1 Business Proposal Assumptions of Volume IIB.

3. SUBSECTION L.13, VOLUME I – WRITTEN TECHNICAL PROPOSAL

INSTRUCTIONS (limit of 60 pages), is hereby deleted in its entirety and replaced with the following:

a) Tab A: Table of Contents (not included in 60-page limit)

Offerors shall include a Table of Contents that identifies and clearly labels the various Volume I sections.

Tab A.1: Acronym Dictionary (not included in 60-page limit)

Offerors shall include an acronym dictionary that defines all acronyms cited in the proposal.

b) Tab B: Past Performance Instructions

Past Performance Questionnaires (PPQs), Attachment J-08, and a summary listing of PPQs are NOT included in the 60-page limit. All other information submitted by the Offeror on Past Performance WILL BE INCLUDED in the 60-page limit.

Offerors shall submit the information described below as part of its written technical proposal for both the Offeror (as prime) and proposed subcontractors.

Offerors may ask references to submit to CMS a PPQ, provided at Attachment J-08, from a maximum of three (3) contracts and/or subcontracts for only non-CMS work (completed and/or currently in progress) for the prime contractor and any subcontractors for the last three (3) years. Contracts listed may include those entered into with the Federal Government, agencies of state and local governments and commercial customers. Offerors and proposed subcontractors shall limit the number of PPQs submitted to no more than three each. PPQs are not required for CMS contract work, as CMS can obtain relevant past performance information from internal sources.

The PPQ (Attachment J-08) must be submitted directly by the references. Attachment J-08 includes a sample cover letter, instructions for questionnaire response and the questionnaire. Offerors shall ask references to submit their responses directly to CMS no later than one (1) week after the proposal due date.

Offerors should include in their technical proposal, under Tab B, a summary listing of each entity that was asked by the Offeror and/or subcontractor to complete a PPQ.

Offerors should not provide copies of letters and blank PPQs mailed to persons for completion. This summary is NOT included in the page limit. This summary should include:

• Contract Number and Type the PPQ is being completed for

• Contact Person completing PPQ

• Contact Person’s Phone Number

• Company Name and Address of Contact Person

• Also provide information on problems encountered on the identified contracts and the offeror’s corrective action

Consistent with FAR 15.305(a), an Offeror having no organizational past performance record may provide references for proposed personnel. The Offeror may describe any quality awards or certifications received in the past three (3) years that it believes indicate the Offeror possesses a high-quality process for developing and producing the services required. Also, describe when the award or certification was bestowed. A joint venture having no past performance history itself may provide references based on the constituent companies.

In addition to Attachment J-08, PPIRS, and/or CPARS, CMS may consider information from a range of internal and external sources to complete its past performance evaluation; including but not limited to the following:

a. Award Fee Determination Letters

b. 912 Evaluations

c. Quality Assurance and Surveillance Plans

d. Reports of Contractor Performance

e. Comprehensive Error Rate Testing (CERT) Results

1. CMS will not consider CERT Results for fiscal year (FY) 2009.

2. CMS will consider CERT Results for FY 2010 related to the Offeror’s achievement towards the Government performance and Results Act (GPRA) goal for that year.

3. CMS will consider CERT Results for FY 2011 related to (1) the Offeror’s achievement towards the GPRA goal for that year, and (2) the Offeror’s improvement on its CERT score from the FY 2010 results.

4. CMS will consider CERT results for FY 2012 related to (1) the Offeror’s achievement towards the GPRA goal for that year, and (2) the Offeror’s improvement on its CERT score from the FY 2011 results.

CMS considers the following document sources of Medicare FI, carrier, and/or MAC performance data to be of lesser relevance to the evaluation of Offerors’ overall past performance than the above-mentioned sources of performance data: (1) Chief Financial Officer’s (CFO) electronic data processing (EDP) audits; (2) Medicare Contractor Provider Satisfaction Survey (MCPSS) results; (3) reviews conducted under OMB Circular A-123; and, (4) SAS-70/SSAE-16 review results. CMS may not consider these four lesser past performance sources in its evaluation (except to the extent that these are captured in PPIRS and/or CPARS).

TAB C: Technical Approach

The Technical Evaluation Panel (TEP) will qualitatively evaluate the Technical Proposal (Volume I) by applying the evaluation factors set forth in Section M.1 below.

Tab C.1: Program Management (included in 60-page limit)

The Offeror shall submit a program management plan that demonstrates its ability to accomplish the effective management of Jurisdiction J for Medicare Parts A and B as a MAC. The program management plan shall include, at a minimum:

• the organizational alignment of the Offeror and its teaming partners/subcontractors for the performance of the MAC contract and the anticipated effects of that alignment in accomplishing (1) the goals of the MAC implementation, and (2) the goals of ongoing MAC operations;

• the demonstration of the Offeror’s establishment of internal controls affecting its employees, teaming partners, subcontractors and consultants.

Tab C.2: Personnel

Tab C.2.1: Staffing Plan (included in 60-page limit)

The Offeror shall submit a staffing plan that presents the Offeror’s staffing strategy for providing and retaining qualified personnel for the life of the contract across the prime and subcontractors.

The Offeror shall identify its proposed staff on this contract as follows:

• Provide an organization chart showing the reporting structure for the staff proposed to fulfill the requirements of the contract.

• Identify the total number of FTEs required for each CLIN of the contract across the prime and subcontractor(s).

• Identify the total number of FTEs required for CLINs 0001 (Implementation), 0002 (Base) and 0003 (Option 1) of the contract across the prime and subcontractor(s) broken out by labor category at thesecond level of the WBS (e.g., C.5.5, C.5.8, etc.), at a minimum. The exception to this is Audit and Reimbursement. The Offeror shall identify its staffing for Audit and Reimbursement separate from C.5.11 at the fourth WBS level (C.5.11.3.2).

• Identify the total number of FTEs at the CLIN level (total FTEs by SLIN totals, no WBS breakouts) for CLINs 0004, 0005, and 0006. For purposes of this submission requirement, the Offeror shall provide the same level of detail as required by the submission requirement under section L.15 (Business Proposal, Volume II.A), less the cost data for CLINs 0004, 0005, and 0006.

The Offeror shall ensure that the FTEs proposed are in place prior to each MAC workload segment cutover and the commencement of production operations as delineated in L.10 above.

As part of its staffing strategy, the Offeror shall describe the number of “experienced” and “inexperienced” staff broken out by labor category and function across the prime and subcontractor(s) at the second level of the WBS (e.g., C.5.5, C.5.8, etc), at a minimum. The exception to this is Audit and Reimbursement. The Offeror shall identify its staffing for Audit and Reimbursement separate from C.5.11 at the fourth WBS level (C.5.11.3.2). The “experienced” label should be used for existing staff or new hires that have experience working in the Medicare Fee-For-Service Program, or equivalent work experience. In addition, for all new hires, the Offeror shall describe the type of work experience previously held. The Offeror shall also describe its recruitment strategy and timeline for obtaining those staff, and contingency plans to respond to staff turnover.

The Offeror shall describe a training approach for staff under the MAC contract. This will include an explanation of the Offeror’s training program and timeline for new hires, and ongoing training and education for staff during the performance of the contract.The Offeror is advised that all staffing plan elements described above shall fully disclose how the Offeror has allocated all personnel for this contract. This includes:

• Any direct labor for the contract,

• Any labor proposed in a service center, and

• If and how personnel is allocated across its indirect pools.

The Offeror is advised to fully disclose any functions and staffing proposed within a service center in its staffing plan, and describe how the use of these service centers support its operational structure for performing this contract. The Offeror shall clearly label any staffing charts or exhibits to identify the information contained within, such as whether FTE counts are only for Direct Labor costs, if FTE counts include subcontractors, etc. If an Offeror includes personnel in its indirect pools, the Offeror shall describe the types of positions contained in these pools that will perform work on this contract and clarify how it has allocated this personnel across its contracts (e.g., assumptions driving percent allocations). NOTE: The Offeror must not make reference to cost or price information.

If the Offeror or proposed subcontractors have service centers, they shall complete Attachment J-29 (Service Center Matrix) to identify levels of effort proposed in a service center for each functional area. PLEASE NOTE: Attachment J-29 is to be completed for Option Year 1 only.