D -- Expert Claim Processing System for Fiscal Intermediary Standard System

A sole source procurement is contemplated to Viable Information Processing Systems (VIPs) of Towson, MD. The Centers for Medicare and Medicaid Services (CMS) intends to obtain a perpetual national license for the VIPS SuperOp software tool. CMS plans to include SuperOp in the Fiscal Intermediary Standard System (FISS) and make it available for all FIs. CMS will also have the option of using SuperOp for other programs as well. VIPs is the only known source that owns the proprietary software license to offer for sale to CMS for the purchase of the SuperOp software tool. SuperOp interfaces with existing systems in order to streamline the processing of health care claim and encounter records by maximizing the level of automation employed in applying edits--policy and processing rules--to electronic records during adjudication. Generally, products like SuperOp have been referred to as 'Expert [claim processing] Systems.' The functions and benefits which SuperOp include are: interception and prevention of online claims errors by replicating the steps examiners go through when resolving such errors; reductions in the number of claims that suspend for manual resolution from batch processing; correction of inconsistent or incorrect bills (minimizing rejections back to providers); application of medical and utilization review guidelines and resolution of third party liability and coordination of benefit errors among other automation of complicated benefit and payment rules; follow-through on suspected or confirmed fraud and abuse situations; creation of an audit trail that remains in history providing the ability to track all edits; and, the use of pre-determined criteria to recognize errors and the comparison of data elements to 'decide' how claims should be processed resulting in the ability to take action to resolve errors. Key to the ability of SuperOp to perform these functions is a user-maintained file of 'events'--logical statements that tell claims processing systems how to recognize a problematic condition, and how to resolve that condition. Currently several medicare contractors have SuperOp as their product of choice. This is NOT a request for competitive proposals and no solicitation is available. Firms that believe they can provide a more efficient and cost effective software tool to perform the functions listed in the previous paragraphs, should identify themselves, their interest, the capability of the tool, and give written notification to the Contracting Officer within 15 days from the publication date of this synopsis. A determination by the Government not to compete the proposed action is solely within the discretion of the Government. Inquiries may be sent to Cathy Baldwin, Contract Specialist, (410)786-5791, or Linda Hook, Contracting Officer, 410-786-8371.