J-01A_Fee-for-Service-Shared-System-Base-Functions.doc

RFP – RRB-11-R-001

Attachment J-01A: Fee-for-Service Shared System Base Functions

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

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

Tele-communications

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

File Transfers

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

The EDC receives files transmitted from CMS approved contractors.

At present, MCS and FISS support a single version of the HIPAA EDI standards. When a subsequent version is adopted as a national standard under HIPAA, it will be necessary for the Contractor to support both the new and the old versions until all users are required to use the new version exclusively.

Perform pre-pass editing and reporting.

MCS furnishes the Professional Provider Telecommunication Network (PPTN) application for provider inquiry of claims status information via a DDE-type screen and a link to the CWF maintained DDE screen established to request and receive beneficiary eligibility information.

Creation of crossover data for the COBC

Creation and execution of jobs to transmit the crossover flat file claims data to the COBC via the Medicare telecommunications network.

FISS furnishes the Direct Data Entry (DDE) application for provider on-line claim entry, correction of institutional claims, determination of claim status and a link to the CWF maintained DDE screen established to request and receive beneficiary eligibility information.

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

Generation of standard IBM AFP mixed mode or Xerox JDL/JDE print file containing development letters (English or Spanish) that support use of contractor-maintained OMR marks or 3 of 9 barcodes Creation and execution of the jobs to transmit the base print output to the contractor local data center

On-line work scheduler

Suspense document print file

Weekly EOLQA sampling

Correspondence application that provides ability to track telephone and written correspondence

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

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

Standard provider profile build logic

Automated pricing of claims

Automated “mass” adjustments capability

Express Adjustments

MSP automated payment calculation

Identification of MSP recovery claims via IRS/SSA Data Match and retroactive recovery with automated history searching

Demand packages in a basic AFP mixed mode or Xerox DJDE print file, along with mailing label print files for certified and non-certified mail

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

Receipt and installation of ECRS software.

· Workload and Performance/PULSE file;

· Appeals;

· Medical Review Workload;

· Medical Review Savings;

· PIMR;

· MSP Savings;

· CFO;

· PSOR

· PS&R

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

Creation and execution of the jobs to transmit the CCI report to CMS’ CCI contractor

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

Accepts the PECOS Daily Export Extract file of provider information, used to merge PECOS data with provider data for claims processing Telecommunications mechanism between the EDC and the PECOS

Retrieval of the Daily Export Extract file from the PECOS (one per Contractor number)

Creation of yearly participating (PAR) provider counts

Creation of a weekly mammography report

Validation of certification numbers for mammography facilities Creation and execution of the jobs to retrieve the Mammography Quality Standard Act (MQSA) File from the CMS data center

MCS creates weekly tapes for the RRB containing provider extract data

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

Bridge between the FISS DDE System and the CWF ELGA screen for eligibility inquiries by providers

Receipt and installation of CWF ELGA software.

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

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

Receipt of the Clears file from the bank (optional)

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

Stale date processing

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

· Basic AFP mixed mode print file;

· Parameters to control additional mail finishing marks;

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

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

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

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

— OR —

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

· Xerox print file;

· Parameters to control additional mail finishing marks;

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

· MSNs and remittance with Xerox JDL/JDE formatted print streams;

· English language printed output for all documents, and Spanish language for the beneficiary MSN;

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

Cash receipts processing

Accounts receivable processing

Accounts payable processing

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

HPSA processing which includes:

· Incentive checks in the same format as other special checks;

· Incentive payment reports;

· HPSA guideline monitoring reports;

· Suppression of HPSA checks for violators

· Notification of providers of those claims for which the HPAA bonus is being paid

Accept standard format NCOA file used to update beneficiary address data Support of telecommunications with vendor

Creation and execution of vendor-specific interfaces for NCOA file (with CMS approval)

Creation and execution of the jobs to transmit the NCOA records to the NCOA vendor or the contractor data center.

Automated history search capability to interface with ARGUS

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

Capability to retrieve information by beneficiary from purged history