DME MAC Jurisdiction B

As required by section 911 of the Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA), CMS must re-compete its Durable Medical Equipment Medicare Administrative Contractors (DME MAC) contracts every five (5) years. The purpose of this contract is to obtain a DME 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 shall perform numerous functions on behalf of Medicare beneficiaries and shall establish relationships with suppliers of Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS), for a defined geographic area or "jurisdiction." The Contractor shall perform the requirements of this contract in accordance with applicable laws, regulations, Medicare manuals and CMS requirements to ensure the financial integrity of the Medicare FFS program. The Medicare FFS program's legal, policy and operating environment is complex, and the Contractor shall utilize or interact with certain CMS-required payment schedules, systems, equipment and/or operational capabilities in the performance of its functions. Further, the Contractor shall coordinate its activities not only with CMS, but also with a broad range of agencies (at the federal, state and local levels of government), other CMS partners and Contractors, and a diverse range of stakeholders within the health care system of the United States. In accordance with CMS' technical specifications, the Contractor shall receive and control Medicare claims from DMEPOS suppliers and beneficiaries within its jurisdiction, as well as perform edits on these claims to determine whether the claims are complete and should be paid. 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 calculates Medicare payment amounts and remits these payments to the appropriate party. The Contractor also conducts a variety of different supplier services, such as answering written inquiries, and educating them on Medicare's rules and regulations and billing procedures. The Contractor also operates Medicare's supplier's toll-free lines across the country to answer a wide-range of supplier questions. Additionally, the Contractor conducts redeterminations on appeals of claims and responds to complex beneficiary inquiries referred from the Beneficiary Contact Centers. CMS anticipates releasing a solicitation for Jurisdiction B (comprised of the states of Illinois, Indiana, Michigan, Minnesota, Ohio, Wisconsin, and Kentucky) on or about August 1, 2014. The contract will include a base year plus four one-year options. The anticipated proposal due date is September 15, 2014 with an anticipated award date of June 1, 2015. This solicitation is expected to be issued as pending availability of funds.