OM Part A East Statement of Work

Attachment J-1 Statement of Work
Requirement No. 260063J
Solicitation No. 75FCMC25QJ056
QIC TASK ORDER - Part A East Workload

STATEMENT OF WORK

I.

SCOPE

The contractor shall provide adjudication services in support of the Medicare, Medicaid, and 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 I.A below. A.

Background

The QIC shall be responsible for all reconsiderations requested as a result of Medicare Administrative Contractors (MACs) redeterminations of Medicare Part A and Part B of A claims. This workload includes processing reconsideration requests for, at a minimum, hospital inpatient, home health, skilled nursing home, hospice, and other Part A services and claims. It also includes institutional claims which are paid from the Part B Trust Fund (sometimes referred to as “Part B of A”). The QIC shall also be responsible for the expedited reconsideration workload comprised of, at a minimum, service termination and hospital discharge reviews performed by Quality Improvement Organizations (QIOs). It shall be noted that the QIC is also responsible for reconsiderations based on “initial determinations” regarding Medicare Secondary Payer (MSP) recovery claims against beneficiaries or providers/suppliers where the redetermination was processed by a MAC. Such recovery claims against beneficiaries routinely include both Part A & Part B claims.
The Part A East jurisdiction is reflected in the table below. Part A East QIC
Covered States
Colorado, New Mexico, Texas, Oklahoma, Arkansas, Louisiana, Mississippi, Alabama, Georgia, Florida, Tennessee, South Carolina, North Carolina, Virginia, West Virginia, Puerto Rico, Virgin Islands, Maine, Vermont, New Hampshire, Massachusetts, Rhode Island, Connecticut, New Jersey, New York, Delaware, Maryland, Pennsylvania, Washington DC. The claims estimates in Section B of this task order (TO) include, but not limited to: standard, expedited, Recovery Audit Contractor (RAC), MSP, Unified Program Integrity Contractors

Attachment J-1 Statement of Work
Requirement No. 260063J
Solicitation No. 75FCMC25QJ056
(UPIC), Supplemental Review Contractor (SMRC), inpatient PPS hospital, long term care, and