RRB_RFP_RRB11R001(SMAC)_SOW_ATT_J01_2-11-11.docx

CMS-RFP-2010-0016

Attachment J-01 Revised 01/28/2010

RFP - RRB-11-R-001

Attachment J-01 as of 2/4/2011

Part B Railroad Specialty Medicare Administrative Contractor

Attachment J-01 - Statement of Work (SOW) for Solicitation RFP – RRB-11-R-001 February 4, 2011

Source Selection Information – See FAR 2.101 and 3.104

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C.2.1.6 Executive Order 13410: Promoting Quality and Efficient Health Care in Federal

C.3 Key Definitions 21

C.5 Functional Requirements 23

C.5.2 Workload Closeout Project Plan (Option that may be exercised at the End of the Contract) 27

C.5.2.3 Workload Closeout Risk Management Plan(Option that may be exercised at the End of the

SPECIALTY MAC PROGRAM MANAGEMENT REQUIREMENTS 72

C.5.8.3.2 Electronic Data Interchange (EDI) Support to Front-end Paper Claims and

C.5.8.7.1 Physician Incentive Payments for Services in Health Professional Shortage Area

C.5.9 Reopening of Medicare Initial Claims Determinations 82

C.5.10 Appeals of Medicare Initial Claims Determinations 84

C.5.11 Provider and Beneficiary Customer Service Programs 90

C.5.11.2 Beneficiary Customer Service 98

C.5.13 Financial Management of Trust Fund Dollars 106

MEDICARE INTEGRITY PROGRAM REQUIREMENTS 119

C.5.17 Provider Outreach and Education (Medicare Integrity) 129

C.5.20 Shipboard/Foreign Travel Services 130

C.7 KEY PERFORMANCE STANDARDS SUMMARY 135

C.1. SCOPE

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

The Contractor shall perform all Medicare Administrative Contractor (MAC) Part B functions on behalf of Railroad Retirement Board (RRB) Medicare beneficiaries as specified in this SOW and outlined in both the Internet-Only-Manuals (IOMs, http://www.cms.hhs.gov/Manuals/IOM/list.asp#TopOfPage) and Paper-Based Manuals. For purposes of this contract, when differences or conflicts occur, this SOW shall take precedence over the IOMs unless otherwise specified. The Contractor shall contact the Contracting Officer (CO) and the Contracting Officer’s Technical Representative (COTR) if budgetary concerns occur because of this conflict. The Contractor is advised that any and all references in the SOW (including manuals, IOMs, etc.) to “RO-Regional Office” shall be replaced with “CO-Contracting Officer” unless otherwise specified in this SOW. Appendix A (see RFP attachment J01B) contains definitions of the abbreviations and acronyms used in this SOW.

C.1.1 Purpose of Contract

The purpose of this contract is to obtain a Railroad Retirement Board Specialty Medicare Administrative Contractor (hereinafter, referred to as “the Contractor” or “RRBSMAC”) to provide specified health insurance benefit administration services, including Medicare Part B claims processing and payment services, in support of the Medicare fee-for-service (FFS) program. The Contractor will perform its responsibilities under the direction of the Railroad Retirement Board and guidance from the Centers for Medicare & Medicaid Services (CMS) to process all Medicare Part B claims and related workloads submitted on behalf of Railroad Retirement Board (RRB) Medicare beneficiaries nationwide.

Under this contract, the Contractor will perform numerous functions to support health care services for RRB Medicare beneficiaries nationwide, which include performing claims-related activities and establishing relationships with providers of health care professional services. The Contractor will perform the requirements of this contract in accordance with applicable laws, regulations, Medicare manuals, and CMS requirements to ensure the financial integrity of the Medicare program. The Medicare program’s legal, policy, and operating environment is complex, and the Contractor will utilize or interact with certain CMS-required payment schedules, systems, equipment, and operational capabilities in the performance of its functions. Further, the Contractor will coordinate its activities not only with the RRB and CMS, but also with a broad range of agencies (at the federal, state, and local levels of government), other RRB and CMS partners and Contractors, and a diverse range of stakeholders within the health care system of the United States.

The Contractor will receive and control Part B Medicare claims for RRB Medicare beneficiaries nationally from professional providers and beneficiaries and will perform standard or required editing on these claims to determine whether the claims are complete and should be paid. In addition, the Contractor will calculate Medicare payment amounts and arrange for remittance of these payments to the appropriate party. The Contractor will validate provider enrollment in CMS’s Provider Enrollment Chain Ownership System (PECOS) through the Provider Enrollment System (PES); conduct redeterminations on appeals of claims; operates a nation-wide Provider Customer Service Program (PCSP) that educates providers about the Medicare program and responds to provider telephone and written inquiries; The Contractor will provide efficient operations of a virtual contact center to handle RRB beneficiary Medicare inquiries nation-wide. The Contractor’s center will also interact with the 1800-Medicare call center when appropriate. The Contractor also will conduct a variety of different provider services, such as obtaining enrollment data on new providers in the program, answering written inquiries, and educating providers on Medicare’s rules, regulations, and billing procedures. The RRBSMAC does not use the PSC and ZPIC contractors the in executing its contractual responsibilities for Railroad Medicare Part B Program Benefit Integrity. The RRBSMAC contractor will perform benefit integrity activities outlined in this SOW (see section C.5.15).

The mission of the RRB is to ensure health care security for its beneficiaries. This contract specifically applies to that mission by fostering excellence in the design and administration of the Railroad Medicare program.

C.1.2 Background

The Medicare program is an integral component of the federal government’s commitment to the health and welfare of the American people, which includes the Social Security system, the Medicaid program (which is primarily administered by the states), and other programs. The Medicare program provides affordable health insurance to (1) eligible individuals aged 65 and over; (2) certain individuals eligible for disability benefits under the Social Security system; and (3) individuals with acute kidney failure (End Stage Renal Disease or ESRD). Approximately 46 million persons were enrolled for Medicare coverage in Fiscal Year (FY) 2009.

Nearly all Medicare beneficiaries may access their insurance benefits through one of two health care delivery systems.

1. First, in all areas of the country, a beneficiary may enroll in the “traditional” Medicare program (the Medicare fee-for-service program) under which benefits are largely provided in keeping with an indemnity insurance model. That is, the beneficiary chooses his/her health care providers, the provider bills for its services to the appropriate Medicare claims administrator, and payment is made to the provider based on the Medicare Hospital Insurance (HI) and/or Supplementary Medical Insurance (SMI) program’s eligibility, coverage and payment rules. The federal government bears all financial (underwriting) risk for the cost of program benefits under this program, and develops detailed administrative requirements and processes to support the claim administration process. As a national entitlement program, there is a strong imperative to provide a common level of benefits and service in all areas of the country while maintaining adequate flexibility to account for local/regional medical practices. More than 79% of all Medicare beneficiaries – or about 36 million- participate in the traditional Medicare program.

2. Second, in many areas of the country, beneficiaries have the option to enroll in one or more privately-sponsored Medicare plans under the “Medicare Advantage” (formerly Medicare+ Choice) program. These private Medicare plans may organize themselves in keeping with one of several health care delivery and payment models (e.g., Health Maintenance Organizations, Preferred Provider Organizations, etc.). These private Medicare plans are required to cover the same basic benefits that the traditional Medicare program offers, but they are given fairly broad responsibility and latitude to set up their internal requirements and processes as they see fit. About 13% of Medicare beneficiaries are currently enrolled in Medicare Advantage.

The Railroad Retirement Board (RRB) is the federal agency created under the Railroad Retirement Acts of 1934, 1935 and 1937, and the Railroad Unemployment Insurance Act of 938. The RRB’s primary function is to administer comprehensive retirement, survivor, unemployment and sickness benefit programs for the nation’s railroad workers and their families. Medicare covers qualified railroad retirement annuitants just as it covers Social Security annuitants. However, in connection with the retirement program, the RRB maintains the administrative responsibilities under the Social Security Act for railroad retirement annuitants’ Medicare Part B eligibility and benefit payments.

The CMS historically contracted with insurance companies to process Medicare claims and perform related support functions, based on geographic territories. The majority of Medicare beneficiaries had their Part B claims processed by insurance carriers under contract with CMS.

Those who qualify for Medicare under the Railroad Retirement Act are an important exception. By statute, the RRB has separate authority to contract for the handling of physician and other Part B claims through a carrier that services railroad retirement annuitants only, as stated in the Social Security Act Section 1842(g).

An agreement between the RRB and SSA, dated May 11, 1966, delegated responsibility and authorized reimbursement to the RRB for enrolling retired and non-retired employees, their spouses, and disabled children for Supplemental Medical Insurance benefits; collecting cash premiums for those benefits; contracting with a carrier to process Supplemental Medical Insurance claims; advising beneficiaries on Supplemental Medical Insurance benefits; and recovering Hospital and supplemental insurance overpayments.

More than 87 percent of all Medicare beneficiaries – or about 46 million – participate in the traditional Medicare program. The recently-enacted Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) includes significant incentives to increase the participation in Medicare Advantage. However, for the next decade at least, a significant majority of all Medicare beneficiaries shall likely remain enrolled in the traditional Fee-For-Service (FFS) Medicare program. FFS coverage in the Medicare Program consists of two distinct parts: (1) Hospital Insurance (HI), (not applicable to these Part B services) which also provides coverage for Medicare institutional benefits; and, (2) SMI, which provides coverage for the professional medical services of physicians and certain other licensed practitioners, as well as coverage for a variety of other services and items (e.g., ambulance, durable medical equipment, etc.). In common usage, the HI program is known as “Medicare Part A,” although both the Part A and B trust funds are used to reimburse institutional claims, and the SMI program is known as “Medicare Part B,” and only the Medicare Part B trust fund is used to reimburse these claims. In FY2008, National Part B sending equated to about $150 billion. Railroad Medicare spending equated to about $844 million

C.1.3 Contracting Reform

On December 8, 2003, the President signed into law the MMA (Public Law 108-173). Section 911 of MMA directed implementation of Medicare FFS Contracting Reform. Medicare Contracting Reform requires that the CMS use competitive procedures to replace its current FIs and carriers with a uniform type of administrative entity, referred to as a MAC. The RRB’s administrative entity is referred to as the RRB Specialty MAC ( RRBSMAC).

C.1.4 Roles and Responsibilities

The roles and responsibilities of the parties are outlined below.

C.1.4.1 The Centers for Medicare & Medicaid Services and the Railroad Retirement Board

The Medicare program’s authorizing statutes charge the Secretary of the Department of Health and Human Services (HHS) with administrative responsibility for the Medicare program. In turn, the Secretary has delegated the program authority for Medicare (both the traditional fee-for-service program as well as Medicare Advantage) to the CMS Administrator.

The CMS administers the Medicare Program, including formulation and promulgation of Medicare Program policy and guidance, contract execution, operation and management, maintenance and review of utilization records, and general Medicare financing. The CMS is the largest purchaser of health care in the United States and provides health care coverage to nearly one in four Americans. The CMS’ annual budget places it among the largest businesses in the world; its programs channel one out of every three dollars in the health care market and its policies influence the other two dollars. In 2006, CMS Contractors, including RRB’s processed approximately 1.15 billion Medicare claims.

As part of its responsibility to administer the Railroad Medicare program, the Railroad Retirement Board (RRB), in coordination and cooperation with CMS, manages the work of its respective Contractor engaged in day-to-day Medicare operation. This management is accomplished through a variety of avenues such as periodic conferences on topics of general interest; targeted sessions with selected subsets of the Contractors; issuance of manual updates describing changes in coverage, pricing, and eligibility; and evaluation of the performance of those Contractors within the description of the work the CMS engages them to do. An exception to CMS jurisdictional authority is the RRB. This exception is explained in detail in Section C.1.2.

C.1.4.1.1 Business Function Leads and Technical Monitors

Within the CMS, specialists on various Medicare topics shall serve as Technical Performance Monitors (TPMs) to assist their Medicare Program Specialists and the Contracting Officers in administering the MAC contracts. The RRB, when necessary, uses these TPMs to provide technical guidance on matters within each TPM’s area of responsibility as it relates to our Contractor’s performance.

The RRBSMAC shall support the RRB and its field offices in their efforts to support CMS and combat fraud and abuse of the Medicare program and protect the Medicare Trust Fund.

C.1.4.2 Medicare Administrative Contractor (“The Contractor”)

Section 1861 of the Social Security Act (“the Act”) defines the items and services for which Medicare may pay. It also defines the provider types recognized by the Medicare program. The Contractor is responsible for handling all Part B claims identified in the Act that are within its jurisdiction

The complexity of Medicare payment systems and policies, and the numbers of Contractors, providers, and insurers involved in the Medicare fee-for-service program create vulnerabilities for error. To minimize these vulnerabilities and reduce the Medicare claims payment error rate, the RRB supports paying claims right the first time, this is one of CMS’s primary goals. This means paying the right amount, to legitimate providers, for Medicare–covered, reasonable and necessary services provided to eligible beneficiaries. Paying right the first time saves resources required to recover improper payments and ensures the proper expenditure of valuable Medicare trust fund dollars.

In the interest of consistency across the Medicare program, during the performance of this contract, the Contractor is expected to seek advice from CMS on questions of law and policy as they arise.

Information relating to Part B MAC claims processing, information flows, interfaces and other supporting processes with “functional Contractors” can be found in both the Concept of Operations document located at the following URL: http://www.cms.hhs.gov/MedicareContractingReform/Downloads/ConOps.pdf and the B Claims Processing Enterprise Architecture which can be found at the following URL: http://www.cms.hhs.gov/MedicareContractingReform/downloads/ProcessingClaimsforPartA&BEnterpriseArchitecture.pdf

C.1.4.3. Jurisdiction-Specific Requirements

The delegation of authority to the Railroad Retirement Board requires the inclusion of the following provision from the CMS Medicare Claims Processing Manual Chapter 12 – Physicians/Non-physician Practitioners Crosswalk to Old Manuals Section 20.7, titled Comparability of Payment Provision of Delegation of Authority by CMS to the Railroad Retirement Board. (Term updates for MACs are in parentheses)

20.7 - Comparability of Payment Provision of Delegation of Authority by CMS to Railroad Retirement Board (Rev. 1, 10-01-03) B3-15064

The delegation of authority, under which the Railroad Retirement Board (RRB) administers the Supplementary Medical Insurance Benefits Program for qualified railroad retirement beneficiaries, requires that:

The Railroad Retirement Board shall take such action as may be necessary to assure that payments made for services by the (Specialty MAC Contractor formerly carrier or) intermediaries it selects will conform as closely as possible to the payment made for comparable services in the same locality by (the Jurisdictional MAC formerly) FI acting for CMS.

The purpose of this comparability of payment is to reduce to the extent possible disparities between the payments made by the (MAC or Contractor formerly) carrier under the RRB delegation and the payments made by CMS’s Jurisdictional MACs for services or items furnished by the same physicians, including provider-based physicians, or suppliers. For all services paid for under the physician fee schedule, carriers under the RRB delegation pay based on the same fee schedule amount used by the Jurisdictional MACs.

C.1.4.4 Reserved

C.2 APPLICABLE DOCUMENTS

The following statutes, regulations, manuals, and documents apply to this contract.

C.2.1 Statues

The Contractor must comply with all applicable laws. The major statute governing the Medicare program is the Social Security Act (Public Law 74-271) (“the Act”), as Amended. The Act and major amendments to the Act are outlined below. The identified amendments include legislation that made significant changes to the Medicare program, are in the process of being implemented, and/or significantly impact the scope of work. Congress may pass new legislation at any time, and CMS must act to implement such legislation as timely and accurately as possible.

C.2.1.1 Social Security Act (Public Law 74-271) The Act was enacted on August 14, 1935, with subsequent amendments. The Act consists of 20 titles, four of which have been repealed. The Hospital Insurance (HI) and Supplementary Medical Insurance (SMI) programs are authorized by Title XVIII of the Act. The vast bulk of traditional Medicare’s program authorizing law is codified in Title XVIII of the Social Security Act, Parts A, B and E (Part C is primarily devoted to private Medicare plans, and the recently-enacted Part D governs the new Medicare prescription drug benefit). Other Medicare-related authorizing statutes may be found in Titles II and XI of the Social Security Act; other governing provisions are in the Internal Revenue Code and other statutes.

To the extent that there is no conflicting Medicare requirement, the administration of the traditional Medicare program is also governed by numerous statutes pertaining to the general administration of federal programs. The following are among the general statutory authorities with broad implications for the traditional Medicare program and the Medicare Administrative Contractor (MAC) contract:

· Rehabilitation Act of 1998 (section 508, Accessibility Standards)

· Financial management and internal controls (e.g., the Federal Managers’ Financial Integrity Act of 1982 (FMFIA), the Chief Financial Officers’ Act of 1990, etc.);

· Federal Information Security Management Act of 2002 (FISMA);

· Government Performance and Results Act (GPRA);

· Personnel and civil rights law (Drug-Free Workplace Act, the Americans with Disability Act.)

· Privacy and information technology requirements (Privacy Act of 1974, Information Technology Management Reform Act of 1996).

C.2.1.2 Medicare Prescription Drug, Improvement, and Modernization Act (MMA) (Public Law 108-173)

On December 8, 2003, the President signed the Medicare Prescription Drug, Improvement and Modernization Act (MMA) into law. This statute makes the most sweeping changes in the structure of the Medicare program since its inception in 1966. The significant changes made by this statute include the following:

· Establishment of a temporary Medicare prescription drug discount card program.

· Establishment of a permanent Medicare prescription drug program.

· Renaming of the Medicare+Choice to Medicare Advantage and provision of significant new incentives to facilitate the participation of private plans in Medicare.

· Provision of certain preventative benefits under both traditional Medicare and Medicare Advantage.

· Implementation of many changes in coverage and payment policy within traditional Medicare.

· Implementation of many administrative and regulatory reforms within traditional Medicare.

· Under section 911 of the MMA, the restructuring of the acquisition statutes that govern traditional Medicare, commonly known as Medicare contracting reform (MCR).

· Under section 912 of the MMA, the requirements for information security program and independent evaluations.

· Under Section 921 of the MMA, provision requiring toll-free lines for provider inquiries and an expansion of provider education.

The work under this contract shall be affected by many of these provisions; however, the primary authority governing the terms and conditions of this contract is section 911.

C.2.1.3 The Health Insurance Portability and Accountability Act of 1996 (Public Law 104-191)

The Health Insurance Portability and Accountability Act (HIPAA) was enacted on August 21, 1996. Title II, Subtitle F, of HIPAA gives the Department of Health and Human Services (DHHS) the authority to mandate the use of standards for the electronic exchange of health care data; to specify what medical and administrative code sets should be used within those standards; to require the use of national identification systems for health care patients, providers, payers (or plans), and employers (or sponsors); and to specify the types of measures required to protect the security and privacy of personally identifiable health care information.

C.2.1.4 Administrative Simplification Compliance Act of 2002 (Public Law 107-105) The Administrative Simplification Compliance Act requires that providers of healthcare submit their claims to Medicare electronically, with limited exceptions, to qualify for payment.

C.2.1.5 The Tax Equity and Fiscal Responsibility Act of 1982 (Public Law 97-248) The Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA) made Medicare the secondary payer for certain employees and dependents.

C.2.1.6 Benefits Improvements and Protection Act of 2000 (Public Law 106-554) Section 521 of the BIPA changed the Medicare appeals process to create a uniform procedure for handling all Medicare appeals (Parts A and B). BIPA also specified new time frames for filing appeals and specified time frames for filing appeals and rendering decisions.

C.2.1.7 Executive Order 13410: Promoting Quality and Efficient Health Care in Federal Government Administered or Sponsored Health Care Programs To the extent applicable and practical, the RRBSMAC shall follow Executive Order 13410: Promoting Quality and Efficient Health Care in Federal Government Administered or Sponsored Health Care Programs. This Executive Order promotes the efficient delivery of quality health care through the use of health information technology, transparency regarding health care quality and price, and incentives to promote the widespread adoption of health information technology and quality of care. To support this mission, the RRBSMAC shall use recognized health information interoperability standards at the time of this contract, in all relevant information technology systems supported, in whole or in part, through this contract.

This includes existing standards from the Health Information Technology Standards Panel (HITSP) that have been recognized by the Secretary of HHS. Specific information regarding the HITSP standards can be found at www.hitsp.org.

C.2.2 Regulations

Generally, Medicare regulations are located in Title 42 and 45 of the Code of Federal Regulations (CFR).

C.2.3 Medicare Manuals

Medicare manuals (e.g., Internet-only manuals—IOMs) are CMS program instructions, day-to-day operating instructions, policies, and procedures that are based on statutes and regulations, guidelines, models, and directives. CMS program components, providers, Contractors, and state survey agencies use Medicare manuals to administer CMS programs. As CMS paper-based manuals are updated, the updated materials are published in the IOMs and eliminated from the paper-based manuals. The IOMs have precedence over paper-based manuals. The CMS will continue this phase-out/phase-in process until all manual instructions are in the IOMs. IOMs and paper-based manuals can be found http://www.cms.hhs.gov/Manuals/IOM/list.asp#TopOfPage.

Citations in this SOW are generally to an IOM Publication (IOM Pub.). Paper-based manual citations are used only where necessary (indicated as CMS Pub. XX).

C.3 KEY DEFINITIONS

Several attachments to the solicitation package including this statement of work (SOW) and the SOW appendix, located in RFP attachment J01B, contain definitions critical to understanding this SOW and the solicitation package. Appendix A is an alphabetical listing of key definitions and Appendix B is a glossary of acronyms used throughout the SOW and the RFP package. These appendices are not intended to be an all-inclusive list of definitions for terms used throughout the SOW. Additional definitions pertinent to this solicitation package and SOWare available on http://www.cms.hhs.gov/apps/glossary/.

C.4 OBJECTIVES

This acquisition supports the mission of RRB to assure health care security for our beneficiaries. Both CMS’s, as well as the RRB’s, strategic goals and objectives emphasize the themes of accountability, stewardship and a renewed focus on the customer. This has resulted in a commitment to RRB beneficiaries as the ultimate focus of all RRB activities, expenditures, and policies. To ensure that RRB remains a responsive, dynamic and relevant government agency that serves its beneficiaries, the RRB/CMS are committed to monitoring and evaluating the effectiveness of its programs.

Consistent with the Government Performance and Results Act (GPRA) principles, RRB, in coordination with CMS has developed and or set forth performance objectives for the Contractor including those in the areas of: customer service, operational excellence and financial management. In this Statement of Work, the RRB, in coordination with CMS, has identified meaningful, outcome-oriented performance standards and measures that speak to the fundamental purposes of the Medicare program and to CMS’ and RRB’s roles as a stewards of taxpayer dollars.

C.4.1 Customer Service

Customer service activities support the business relationship between fee-for-service Medicare providers/suppliers and the RRB Medicare beneficiary program. Quality services to both groups increase the overall level of customer satisfaction. In support of this objective, the Contractor shall:

· Maintain effective provider education that achieves accurate billing with prompt and correct provider/supplier payment;

· Respond to RRB Medicare beneficiary telephone and written inquiries promptly, clearly, and accurately.

· Respond to provider telephone and written inquiries promptly, clearly, and accurately.

· Maintain a high level of beneficiary service and satisfaction related to the complex inquiries referred to RRBSMAC by the Beneficiary Contact Center.

· Maintain a high level of provider service and satisfaction by good communication and relationships with providers.

· Maintain effective provider education that achieves accurate billing with prompt and correct payment.

C.4.2 Operational Excellence

Operational Excellence addresses the ability of employees, the quality of information systems, and the effects of organizational alignment in supporting the accomplishment of organizational goals. In support of achieving operational excellence, the Contractor shall do the following:

· Promote corporate integrity and establish internal controls and an effective compliance program to achieve contractual goals and objectives.

· Work collaboratively with RRB, CMS, providers, and other CMS contractors to foster integration of Medicare operations.

C.4.3 Innovation and Technology

Innovation and Technology addresses internal business results that lead to financial success and satisfied customers. In support of Innovation and Technology, the Contractor shall do the following:

· Foster efficiencies in the administration of the RRB Part B Medicare program to promote best value for the Government.

· Develop and continually refine business processes to foster excellence and quality in the administration of the RRB Part B Medicare program.

· Use innovation and creative solutions to improve the nation-wide RRB program operation.

C.4.4 Financial Management Improving financial management is a key initiative in the President’s Management Agenda and has been a long-term focus in achieving RRBs and CMS’ mission. Under the Medicare Integrity Program (MIP), the RRB is focused on paying the right amount to legitimate providers for covered, reasonable and necessary services. Financial management also addresses efforts to promote cost efficiency and the ability to deliver maximum value to the customer. In support of financial management, the Contractor shall do the following:

a. Promote the fiscal integrity of the Medicare FFS program and be an accountable steward of public funds.

b. Pay Part B claims and process overpayments timely, accurately, and reliably.

C.5 FUNCTIONAL REQUIREMENTS

The Contractor shall perform all RRBSMAC functions specified in this Statement of Work and outlined in the Internet-Only Manuals (IOMs). For purposes of this contract, any IOM instructions/references to “Fiscal Intermediaries” or “Intermediaries” are not applicable to this Statement of Work. When differences or conflicts occur, this Statement of Work shall take precedence over the IOMs unless otherwise specified by the Contracting Officer. The Contractor shall contact the Contracting Officer and the Project Officer if budgetary concerns occur because of this conflict.

C.5.1 Workload Implementation Requirements

The Contractor shall carry out the orderly transfer of all Medicare data, records, and operations from the outgoing carrier for the jurisdiction in accordance with the Jurisdiction Implementation Project Plan.

During the implementation period, the term “transition” will be applied to activities that are being performed by more than just the incoming Contractor; i.e., others involved in the project such as the outgoing contractor, data center, etc. The term “implementation” is used for those activities normally associated with just the incoming Contractor. However, in general usage, the term “transition” often will be applied to the incoming Contractor’s implementation activities.

A workload implementation is defined as the entire scope of contractor activities associated with moving RRB Medicare functions from the outgoing Contractor.

A workload implementation is successful when the transfer of RRB Medicare data, records, and operational activities from the outgoing Contractor to the incoming (RRBSMAC) Contractor is accomplished so that:

· There is minimal disruption to beneficiaries;

· There is minimal disruption to providers;

· There is no disruption of claims processing and Medicare operations;

· The implementation is completed within the required time period as stated in the Implementation Project Plan;

· Actual costs represent effective and efficient use of resources; and

· All parties with an interest in the implementation (whether direct or indirect) are kept informed of the implementation’s status and progress.

The Contractor shall establish and maintain through the course of the implementation an experienced implementation management team.

C.5.1.1 Jurisdiction Implementation Project Plan

The Contractor shall develop, execute, and maintain a Jurisdiction Implementation Project Plan consistent with the Contractor’s proposed Jurisdiction Implementation Project Plan, submitted in their final proposal, and report its status. The Jurisdiction Implementation Project Plan shall include a detailed description of all activities required to transfer all RRB Medicare operations from the current carrier.

The contractor shall submit the Implementation Project Plan immediately upon contract award.