OM DME QIC Statement of Work Request for Information

Attachment 1 – Statement of Work

HHSM-500-2004-00007I-75FCMC23F0001

Durable Medical Equipment
Qualified Independent Contractor (DME QIC)

STATEMENT OF WORK

I.

SCOPE

The contractor shall provide adjudication services in support of the Medicare, Medicaid, and State Children’s Health Insurance Program Benefits Improvement and Protection Act of 2000 (BIPA), Public Law 106-554, Subtitle C - Changes in Medicare Coverage and Appeals Process, Section 521 Revisions to Medicare Appeals Process. More specifically, the contractor shall act as a “Qualified Independent Contractor” (QIC) responsible for conducting reconsiderations of initial Medicare claims determinations in the jurisdiction identified in Section A below. A.

Background

The DME QIC workload includes, at a minimum, processing reconsideration requests in accordance with 42 CFR Part 405 for Medicare fee-for-service claims related to durable medical equipment (including, but not limited, wheelchairs, hospital beds, oxygen, and walkers), prosthetics and orthotics (P & O), parenteral and enteral nutrition (PEN), and supplies. DME QIC Reconsiderations Workload:
There is only one DME QIC jurisdiction for processing reconsiderations on DME claims. The workload estimate in the Letter Request for Proposal (LRFP) includes all reconsideration activities under this task order including but not limited to: Durable Medical Equipment Medicare Administrative Contractor (DME MAC), Recovery Audit Contractor (RAC), Unified Program Integrity Contractor (UPIC), and Supplemental Medical Review Contractor (SMRC) appeals.
The workload estimates are reflected in the LRFP by period of performance (POP). Claims received shall be billed against the POP in which they are received even if the case/claims are completed by the DME QIC in a subsequent POP. For example, a claim received during the 12month Base Operational Period shall be billed against the appropriate Contract Line-Item Number (CLIN) for the Base Period even if the case/claim is not completed/closed until Renewal I.
In addition, each claim may only be billed to the task order once. All subsequent actions on the claim including, but not limited to, reopenings, corrected letters, Administrative Law Judge (ALJ) remands, and corrected dismissals (including claims that were previously dismissed for no redetermination) will not be reimbursed separately.
For any cases that contain more than 250 claims, the QIC shall contact the Contracting Officer’s Representative (COR) to discuss utilizing statistical extrapolation for that case in accordance