OM Part B South Statement of Work

APP 250600
Attachment J-1
Statement of Work
QIC Task Order (TO) – Part B QIC South 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.B below. A.

Background

Part B QIC Workload
The QIC shall be responsible for all reconsiderations requested as a result of Medicare Administrative Contractors (MACs) redeterminations of Medicare Part B claims. The Part B workload includes, at a minimum, processing reconsideration requests for doctor’s services, outpatient medical and surgical services, diagnostic tests, and ambulatory surgery. It also includes outpatient mental health care, and outpatient physical and occupational therapy. The Part B South jurisdiction is reflected in the table below.

Part B South QIC
Covered States
Colorado, New Mexico, Texas, Oklahoma, Arkansas, Louisiana, Mississippi, Tennessee, Alabama, Georgia, Florida, North Carolina, South Carolina, Virginia, West Virginia, Puerto Rico, Virgin Islands
Note: Railroad Retirement Board reconsiderations are also included in this workload jurisdiction.
The claims estimates in Section B of this task order (TO) include all reconsideration activities under this TO, including but not limited to Medicare Secondary Payer (MSP), Unified Program Integrity Contractors (UPICs), Supplemental Review Contractor (SMRC), and Recovery Audit Contractor (RAC) appeals.
The workload estimates are delineated 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 in a

APP 250600
Attachment J-1
Statement of Work
subsequent POP. For example, a claim received during the 12-month Base Operational Period shall be billed against the appropriate Contract Line Item Number (CLIN)/Sub-Line Item (SLIN) for the Base Operational Period even if the case/claim is not completed/closed until Renewal Period I.
In addition, each claim may only be billed to the TO once. Any and all subsequent actions on the claim, including but not limited to reopenings, corrected letters, Administrative Law Judge