J-01B SOW appendices.docx

RFP – RRB-11-R-001

Attachment J-1B Statement of Work Appendices

APPENDICES

A. KEY DEFINITIONS

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

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

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

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

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

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

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

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

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

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

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

“Bill” - see “Claim.”

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

“Business Requirements Notification” means a CMS Change Request (CR) form used to communicate new instructions or updates or clarifications to existing instructions.

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

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

“Claim” means a transaction submitted by a provider or beneficiary that meets all the requirements in 42 CFR 424.30-424.44. (See also “recovery claim.”)

“Claims-related transaction” means a transaction other than a claim, which the contractor must process. This includes but is not limited to HIPAA related transactions and Method Selection forms for home dialysis.

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

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

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

“Compliance Error Rate (CERT) Testing ” CERT is a program initiated to monitor the accuracy of Medicare Fee-for-Service (FFS) payments. The CERT contractor calculates the error rate for the MAC. In order to gain insight into the causes of errors, CMS produces a national paid claims error rate, a contractor specific error rate, and provider compliance error rates. For more information, refer to the “Improper Medicare Fee-for-Service Payment Report” at http://www.cms.hhs.gov and to IOM Pub 100-8 Chapter 22.

“Complex Beneficiary Inquiries” means those inquiries (telephone or written) from Medicare beneficiaries that cannot be resolved by the 1-800Medicare Beneficiary Contact Center because further research is required or no desktop scripting exists addressing the issue but will be passed on to the appropriate MAC Contractor for reolution.

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

“Confidential Notification” means a CMS Change Request (CR) form used to request system or non-system changes that are not to be shared with the Medicare provider or beneficiary community.

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

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

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

“Days” means Federal business days unless otherwise specified.

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

“Desk Review” means an analysis of the provider’s cost report to determine its adequacy and completeness, accuracy, and reasonableness of the data recorded, and a summary of review results to either settle the cost report without field audit (including any problem resolution) or to determine the extent to which field audit verification, including an on-site review, is required.

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

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

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

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

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

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

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

“Federally Qualified Health Centers” provide primary care services to people with Medicare, Medicaid, SCHIP, and the uninsured in underserved rural and urban communities, as well as Indian outpatient health programs. The services provided by the FQHCs are similar to those of RHCs, but also include preventative primary services.

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

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

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

“Freestanding home health agency” refers to an entity that furnishes home health service that is not integrated with any other entity as a main provider, a department of a provider, remote location of a hospital, satellite facility, or a provider-based entity.

“Freestanding Hospice” refers to an entity that furnishes hospice services that is not integrated with any other entity as a main provider, a department of a provider, remote location of a hospital, satellite facility, or a provider-based entity.

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

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

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

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

“Health Professional Shortage Area” (HPSA) means a geographic area designated by the Public Health Service as a health professional shortage area.

“Healthcare Integrated General Ledger Accounting System” (HIGLAS) means a single, unified general ledger accounting system that will support all MAC contractors and CMS central office administrative accounting.

“Home Health Agency” means a public agency or private organization, or a subdivision of such an agency or organization, which meets the requirements described in IOM Pub 100-01, Chapter 5, §50.

“Hospice” means a public agency or private organization or a subdivision of either that is primarily engaged in providing care to terminally ill individuals and meets the conditions of participation for hospices, and has a valid provider agreement.

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

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

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

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

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

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

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

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

“Joint Signature Memorandum/Technical Direction Letter” (JSM/TDL) means a formal CMS communication vehicle used for administrative announcements, emergency alerts, and one-time informational requests that do not involve shared system changes.

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

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

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

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

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

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

· Implement local coverage determinations, and

· Workaround shared system limitations.

“Low/no Medicare utilization cost reports” means a provider that either has not furnished any covered services to Medicare beneficiaries during the entire cost reporting period or that had low utilization of covered services by Medicare beneficiaries in a reporting period and received correspondingly low interim reimbursement payments. The cost reports required for these providers would be less than a full cost report, as authorized by the contractor. See CMS Pub. 15, Provider Reimbursement Manual, Part II, section 110.

“Mail” means regular first-class mail delivered by the U.S. Postal Service, unless otherwise specified.

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

“Medicare data” means any representation of information, in electronic or physical form, pertaining to Medicare beneficiaries, providers, physicians, suppliers, or practitioners, or information necessary for the contractual administration thereof, that is received, maintained, processed, manipulated, stored, or provided to others in the performance of the functions described in a Medicare contract. See also “Medicare file” and “Medicare record.”

“Medicare file” means a set or collection of related Medicare records treated as a unit. See also “Medicare data” and “Medicare record.”

“Medicare record” means a collection of related items of Medicare data treated as a unit. See also “Medicare data” and “Medicare file.”

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

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

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

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

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

“Multi Carrier System” (MCS) means the shared system used to process Part B professional services claims.

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

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

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

“One-Time Notification” means a CMS Change Request (CR) form used to communicate one-time instructions to MACs, Shared System Maintainers (SSMs), and the CWF maintenance contractor.

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

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

“Outpatient Code Editor” (OCE) means a software editor employed to check the accuracy of claims relative to procedural/diagnostic coding on Medicare FFS outpatient institutional claims.

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

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

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

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

“Periodic Interim Payment” (PIP) means a periodic payment made to certain Medicare institutional providers for services delivered not tied to receipt of claims, but later reconciled against payment due when claims are received.

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

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

“Professional claims” means claims for services that must be submitted to Medicare for FFS processing in a HIPAA approved electronic claim standard format or sometimes on a CMS 1500 (08-05) paper claim form. These claims are paid only from the Medicare Part B trust fund.

“Professional providers” means physicians, practitioners, and suppliers that must submit professional claims to Medicare for FFS processing. Attachment J-2, Categories of Benefits and Provider/Supplier Types for the MAC Contract, contains a list of professional providers.

“Program Safeguard Contractor” (PSC) means a contractor that performs specific program integrity functions under section 1893 of the Social Security Act such as audit, medical review, and potential fraud and abuse investigations and case referrals, and some specialty functions (CERT, etc.). Being replaced with ZPICs – Zone Program Integrity Contractors.

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

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

“Provider agreement” means a Health Insurance Benefit Agreement, which is an agreement between the Secretary of DHHS and a provider, in which the provider agrees to conform to section 1866 of the Social Security Act in order to receive payment under Title XVIII of the Act.

“Provider-based determination” means a determination that a facility or organization, which has been created by or acquired by a main provider to furnish health care services different from the main provider’s, merits provider-based status for payment purposes.

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

“Provider compliance error rate” means a rate that is based on how the claims look when they first arrive at the contractor, before the contractor applies any edits or conducts any reviews. The provider compliance error rate is a good indicator of how well the contractor is educating the provider community because it measures how well providers prepare claims for submission. This error rate is based on dollars. For more information on the calculation of this error rate please refer to the Improper Medicare Fee-for-Service Payment Report at http://www.cms.hhs.gov.

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

“Provider Enrollment Chain and Ownership System (PECOS)” is a Medicare Provider Enrollment system that captures information contained within the Medicare Enrollment Forms. It is a secured system that provides access to specified functions for authorized users.

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

“Quality Improvement Organization” (QIO) means an organization comprising a group of practicing doctors and other health care experts that are paid by the federal government to review and improve the care given to Medicare patients as described in Title 11 of the Social Security Act.

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

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

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

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

“Recurring Update Notification” means a CMS CR form used to communicate regularly scheduled or annual instructions, changes and updates to CMS-supplied software and software documentation, fee schedules, the federal interest rate percentage, and code sets and other intermittently issued information.

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

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

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

“Rural Health Clinic” (RHC) means an outpatient facility that is primarily engaged in furnishing the services of physicians and other medical and health services and that meets other requirements designated to ensure the health and safety of individuals served by the clinic. The clinic must be located in a medically underserved area that is not urbanized as defined by the Census Bureau.

“Segment” means the Part A or Part B workload that a given outgoing contractor processes in any one jurisdiction and that would be assumed by the contractor. It also refers to a block of a specific type of information in X12 transaction format.

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

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

“Settlement” means the process of incorporating adjustments to a cost report derived from the contractor’s review and issuing a Notice of Program Reimbursement (NPR). (For MSP, see “MSP settlement.”)

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

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

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

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

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

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

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

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

“Transition closeout period” means the time between the award of a jurisdiction to a new contractor and the end of the incumbent contractor’s (Fiscal Intermediary—FI, carrier, or MAC) contract.

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

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

“Uniform Desk Review” (UDR) means a written program required for all providers filing Medicare cost reports. The objective of the UDR is to determine whether the cost report can be settled without audit, needs an onsite review, or needs an audit, and to determine the scope of audit or on-site review, as appropriate. The UDR comprises an accessibility checklist, a threshold parameter, a clerical portion, and a desk review.

“Unique Physician/Practitioner Identification Number” (UPIN) was a unique identifier for each physician, practitioner or group practice that provides services for which Medicare payment is made. The UPIN was replaced by the NPI in all but a minor number of instances.

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

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

“Zone Program Integrity Contractor” (ZPIC) means a contractor that performs specific program integrity functions under section 1893 of the Social Security Act such as audit, medical review, and potential fraud and abuse investigations and case referrals, and some specialty functions (CERT, etc.). These are replacing the Program Safeguard Contractors.

B. ACRONYM LIST