A/B MAC Jurisdiction J (formerly MAC Jurisdiction 10)

As required by section 911 of the Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA), CMS must re-compete its Part A & B Medicare Administrative Contractor (A/B MAC) contracts every five (5) years. The purpose of this contract is to obtain an A/B MAC (hereinafter, referred to as "the Contractor") to provide specified health insurance benefit administration services, including Medicare claims processing and payment services, in support of the Medicare FFS program. The contractor shall perform its responsibilities under the direction of CMS. The Contractor will perform numerous functions to support health care services for Medicare beneficiaries, which include performing claims-related activities and establishing relationships with providers of health care services, both institutional and professional, for a defined geographic area or "jurisdiction." The Contractor will perform the requirements of this contract in accordance with applicable laws, regulations, Medicare manuals, as well as CMS requirements to ensure the financial integrity of the Medicare program. The Medicare program has complex legal, policy, and operating environments. The Contractor will utilize and interact with all pertinent CMS-required payment schedules, systems, equipment, and operational capabilities in the performance of its functions. Further, the Contractor will not only coordinate its activities with CMS, but must also work with a broad range of Federal, State, and Local government agencies, CMS partners and Contractors, and any other stakeholder in the health care system of the United States. In accordance with CMS' technical specifications, the Contractor shall receive and control Medicare claims from institutional and professional providers, suppliers, and beneficiaries within its jurisdiction, and will perform all standard or otherwise required editing with respect to these claims to determine whether they are complete and ready for payment. An edit is defined as "logic within the Standard Claims Processing System (or PSC/ZPIC Supplemental Edit Software) that selects certain claims, evaluates or compares information on the selected claims or other accessible source, and, depending on the evaluation, takes action on the claims, such as pay in full, pay in part, or suspend for manual review." In addition, the Contractor will calculate Medicare payment amounts and remit those payments to the appropriate party. The Contractor also will conduct redeterminations with respect to appeals of claims; operate a Provider Customer Service Program (PCSP) which will educate providers with respect to the Medicare program; will respond to provider telephone and written inquiries; will respond to complex inquiries from Beneficiary Contact Centers (BCCs); and will make coverage decisions for new procedures and devices in local areas. The Contractor also will conduct a variety of provider services, such as enrollment of new providers in the program, answering written inquiries, and educating providers with respect to Medicare's rules, regulations, and billing procedures. CMS anticipates releasing a solicitation for Jurisdiction J (which includes the states of Alabama, Georgia and Tennessee) on or about January 18, 2013. The contract will include a base year plus four one-year options. The proposal due date is March 8, 2013 with an anticipated award date of August 30, 2013. This solicitation is expected to be issued as pending availability of funds.