A/B MAC Jurisdiction K (previously Jurisdictions 13 and 14)

As required by section 911 of the Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA), CMS must re-compete its Part A & B Medicare Administrative Contractor (A/B MAC) contracts every five (5) years. The purpose of this contract is to obtain a A/B MAC (hereinafter, referred to as "the Contractor") to provide specified health insurance benefit administration services, including Medicare claims processing and payment services, in support of the Medicare FFS program. The Contractor shall perform its responsibilities under the direction of CMS.

The Contractor will perform numerous functions to support health care services for Medicare beneficiaries, which include performing claims-related activities and establishing relationships with providers of health care services, both institutional and professional, for a defined geographic area or "jurisdiction." 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 CMS, but also with a broad range of agencies (at the federal, state, and local levels of government), other CMS partners and Contractors, and a diverse range of stakeholders within the health care system of the United States.

In accordance with CMS' technical specifications, the Contractor shall receive and control Medicare claims from institutional and professional providers, suppliers, and beneficiaries within its jurisdiction and will perform standard or required editing on these claims to determine whether the claims are complete and should be paid. An edit is defined as "logic within the Standard Claims Processing System (or PSC/ZPIC Supplemental Edit Software) that selects certain claims, evaluates or compares information on the selected claims or other accessible source, and, depending on the evaluation, takes action on the claims, such as pay in full, pay in part, or suspend for manual review."

In addition, the Contractor calculates Medicare payment amounts and remits these payments to the appropriate party. The Contractor also will enroll new providers; conduct redeterminations on appeals of claims; operate a Provider Customer Service Program (PCSP) that educates providers about the Medicare program and responds to provider telephone and written inquiries; respond to complex inquiries from Beneficiary Contact Centers (BCCs); and make coverage decisions for new procedures and devices in local areas. The Contractor also will conduct a variety of different provider services, such as enrolling new providers in the program, answering written inquiries, and educating providers on Medicare's rules, regulations, and billing procedures.

 The solicitation is issued pending availability of funds.