QIC IDIQ Umbrella Statement of Work

Attachment J-1

QUALIFIED INDEPENDENT CONTRACTOR

(QIC)

UMBRELLA STATEMENT OF WORK

Attachment J-1

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, and the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003 Public Law 108-173. More specifically, the contractor shall act as a “Qualified Independent Contractor” (QIC) responsible for conducting reconsiderations of initial Medicare claims determinations and service requests. The overarching goal of having QICs perform reconsiderations is to issue informative and accurate decisions which will lead to a reduction in the number of unnecessary appeals filed, dismissals issued and reopenings requested. In addition, one of the selected contractors shall perform administrative services associated with conducting Medicare Part A and Part B reconsiderations and shall be known as the Administrative QIC or the “AdQIC.” Administrative services related to Part C and Part D reconsiderations shall be performed as set out in the statements of work for the Part C QIC and Part D QIC.

I. A

Background

This chapter provides background material necessary to understand the purpose and requirements of this Umbrella Statement of Work (USOW).

I.A.1

Medicare Part A and Part B

Medicare is a nationwide, federal health insurance program enacted in 1965 as title XVIII of the Social Security Act (the Act). Medicare provides health insurance for people 65 years of age or older, certain younger disabled persons, and persons with permanent kidney failure (end stage renal disease). Beneficiaries may choose between the traditional, fee-for-service Medicare program, or a private health plan option referred to as Medicare Advantage Program. The Medicare program consists of two primary parts: •

Hospital Insurance (HI), also known as “Part A;” and

•

Supplementary Medical Insurance (SMI), also known as “Part B.”

Medicare Part A covers some of the costs of providing medically necessary inpatient hospital care, skilled nursing facility care following a hospital stay, home health care, and hospice care. Individuals entitled to Social Security or Railroad Retirement benefits are automatically entitled to Part A hospital insurance beginning with the first day of the month in which the individual attains the age of 65. Those younger than age 65 who