Part C QIC - Statement of Work

Part C Qualified Independent Contractor (QIC)
Attachment J-1: Statement of Work
Medicare Part C Qualified Independent Contractor (QIC) Task Order Statement of Work
I.

SCOPE

The contractor shall provide adjudication services in support of the coverage determinations, reconsiderations, and appeals requirements set forth at section 1852(g) of the Social Security Act (the Act), as amended by Title II of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) (Pub. L. 108-173). The contractor shall act as an independent review entity (IRE), hereinafter referred to as the Part C Qualified Independent Contractor (QIC), responsible for conducting reconsiderations of adverse organization determinations and adverse reconsiderations made by Medicare Advantage (MA) organizations. Organization determinations and reconsiderations include the amount of cost sharing, if any, that the enrollee is required to pay. The contractor is also responsible for reviewing MA organization dismissals of appellant reconsideration requests.
The contractor’s workload shall also include conducting reconsiderations of adverse determinations by cost contracts (under section 1876 of the Act), Health Care Prepayment Plans (HCPPs) (under section 1833 of the Act), any CMS approved Medicare managed care demonstrations where the Medicare requirements for appeals and independent review have not been waived by CMS, and PACE organizations (under section 1894 of the Act). For purposes of this Task Order (TO), the entities identified in the two prior paragraphs shall be referred to as Part C plans.
I.A.

Background:

CMS has issued final regulations that establish procedures for grievances, organization determinations, and appeals under the MA program. These regulations are set forth at 42 CFR Part 422, Subpart M. Effective January 1, 2006, cost plans and HCPPs began following the appeal procedures at Part 422, Subpart M. The PACE program regulations concerning the appeals process are set forth at 42 CFR Part 460, Subpart G (see 42 CFR § 460.122 - 124). The following sections provide an overview of the most salient features of the Part C appeals process for purposes of this TO.
I.A.1. Overview of the Part C Appeals Process:
The MA program was enacted in Title II of the MMA and replaced the Medicare+Choice (M+C) program established under Part C of Title XVIII of the Act, while retaining most key features of the M+C program. Accordingly, Part C plans must have standard and