[Federal Register: September 29, 2006 (Volume 71, Number 189)]
[Notices]
[Page 57513-57519]
From the Federal Register Online via GPO Access [wais.access.gpo.gov]
[DOCID:fr29se06-86]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
[CMS-1333-GNC]
RIN: 0938-ZA94
Medicare Program; Criteria and Standards for Evaluating
Intermediary and Carrier Performance During Fiscal Year 2007
AGENCY: Centers for Medicare and Medicaid Services (CMS), HHS.
ACTION: General notice with comment period.
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SUMMARY: This general notice with comment period describes the criteria
and standards to be used for evaluating the performance of fiscal
intermediaries (FIs) and carriers in the administration of the Medicare
program.
The results of these evaluations are considered whenever we enter
into, renew, or terminate an intermediary agreement, carrier contract,
or take other contract actions, for example, assigning or reassigning
providers or services to an intermediary or designating regional or
national intermediaries. We are requesting public comment on these
criteria and standards.
DATES: Effective Date: The criteria and standards are effective on
October 1, 2006.
Comment Date: To be assured consideration, comments must be
received at one of the addresses provided below, no later than 5 p.m.
on November 28, 2006.
ADDRESSES: In commenting, please refer to file code CMS-1333-GNC.
Because of staff and resource limitations, we cannot accept comments by
facsimile (fax) transmission.
[[Page 57514]]
You may submit comments in one of four ways (no duplicates,
please):
1. Electronically. You may submit electronic comments on specific
issues in this regulation to http://www.cms.hhs.gov/eRulemaking. Click
on the link ``Submit electronic comments on CMS regulations with an
open comment period.'' (Attachments should be in Microsoft Word,
WordPerfect, or Excel; however, we prefer Microsoft Word.)
2. By regular mail. You may mail written comments (one original and
two copies) to the following address only: Centers for Medicare &
Medicaid Services, Department of Health and Human Services, Attention:
CMS-1333-GNC, P.O. Box 8012, Baltimore, MD 21244-8012.
Please allow sufficient time for mailed comments to be received
before the close of the comment period.
3. By express or overnight mail. You may send written comments (one
original and two copies) to the following address only: Centers for
Medicare & Medicaid Services, Department of Health and Human Services,
Attention: CMS-1333-GNC, Mail Stop C4-26-05, 7500 Security Boulevard,
Baltimore, MD 21244-1850.
4. By hand or courier. If you prefer, you may deliver (by hand or
courier) your written comments (one original and two copies) before the
close of the comment period to one of the following addresses. If you
intend to deliver your comments to the Baltimore address, please call
telephone number (410) 786-7195 in advance to schedule your arrival
with one of our staff members. Room 445-G, Hubert H. Humphrey Building,
200 Independence Avenue, SW., Washington, DC 20201; or 7500 Security
Boulevard, Baltimore, MD 21244-1850.
(Because access to the interior of the HHH Building is not readily
available to persons without Federal Government identification,
commenters are encouraged to leave their comments in the CMS drop slots
located in the main lobby of the building. A stamp-in clock is
available for persons wishing to retain a proof of filing by stamping
in and retaining an extra copy of the comments being filed.)
Comments mailed to the addresses indicated as appropriate for hand
or courier delivery may be delayed and received after the comment
period.
For information on viewing public comments, see the beginning of
the SUPPLEMENTARY INFORMATION section.
FOR FURTHER INFORMATION CONTACT: Lee Ann Crochunis, (410) 786-3363.
SUPPLEMENTARY INFORMATION: Submitting Comments: We welcome comments
from the public on all issues set forth in this notice to assist us in
fully considering issues and developing policies. You can assist us by
referencing the file code CMS-1333-GNC and the specific ``issue
identifier'' that precedes the section on which you choose to comment.
Inspection of Public Comments: All comments received before the
close of the comment period are available for viewing by the public,
including any personally identifiable or confidential business
information that is included in a comment. We post all comments
received before the close of the comment period on the following Web
site as soon as possible after they have been received: http://www.cms.hhs.gov/eRulemaking.
Click on the link ``Electronic Comments on
CMS Regulations'' on that Web site to view public comments.
Comments received timely will also be available for public
inspection as they are received, generally beginning approximately 3
weeks after publication of a document, at the headquarters of the
Centers for Medicare & Medicaid Services, 7500 Security Boulevard,
Baltimore, Maryland 21244, Monday through Friday of each week from 8:30
a.m. to 4 p.m. To schedule an appointment to view public comments,
phone 1-800-743-3951.
I. Background
A. Medicare Part A--Hospital Insurance
Under section 1816 of the Social Security Act (the Act), public or
private organizations and agencies participate in the administration of
Part A (Hospital Insurance) of the Medicare program under agreements
with CMS. These agencies or organizations, known as fiscal
intermediaries (FIs), determine whether medical services are covered
under Medicare, determine correct payment amounts and then make
payments to the health care providers (for example, hospitals, skilled
nursing facilities (SNFs), and community mental health centers) on
behalf of the beneficiaries. Section 1816(f) of the Act requires us to
develop criteria, standards, and procedures to evaluate an FI's
performance of its functions under its agreement.
Section 1816(e)(4) of the Act requires us to designate regional
agencies or organizations, which are already Medicare FIs under section
1816 of the Act, to perform claim processing functions for freestanding
home health agency (HHA) claims. We refer to these organizations as
Regional Home Health Intermediaries (RHHIs) (See Sec. 421.117 ).
The evaluation of intermediary performance is part of our contract
management process. These evaluations need not be limited to the
current fiscal year (FY), other fixed term basis, or agreement term.
B. Medicare Part B--Supplementary Medical Insurance
Under section 1842 of the Act, we are authorized to enter into
contracts with carriers to fulfill various functions in the
administration of Part B, Supplementary Medical Insurance of the
Medicare program. Beneficiaries, physicians, and suppliers of services
submit claims to these carriers. The carriers determine whether the
services are covered under Medicare and the amount payable for the
services or supplies, and then make payment to the appropriate party.
Under section 1842(b)(2) of the Act, we are required to develop
criteria, standards, and procedures to evaluate a carrier's performance
of its functions under its contract. Evaluations of Medicare fee-for-
service (FFS) contractor performance need not be limited to the current
FFY, other fixed term basis, or contract term. The evaluation of
carrier performance is part of our contract management process.
C. Development and Publication of Criteria and Standards
In addition to the statutory requirements, Sec. 421.120, Sec.
421.122 and Sec. 421.201 of the regulations, provide for publication
of a Federal Register notice to announce criteria and standards for
intermediaries and carriers before the beginning of each evaluation
period. We published the current criteria and standards for
intermediaries, carriers, and DMEPOS regional carriers in the general
notice with comment on September 23, 2005 (70 FR 55887).
To the extent possible, we make every effort to publish the
criteria and standards before the beginning of the Federal Fiscal Year
(FFY), which is October 1. If we do not publish a Federal Register
notice before the new FFY begins, readers may presume that until and
unless notified otherwise, the criteria and standards that were in
effect for the previous FFY remain in effect.
In those instances in which we are unable to meet our goal of
publishing the subject Federal Register notice before the beginning of
the FFY, we may publish the criteria and standards notice at any
subsequent time during the year. If we publish a notice in this manner,
the evaluation period for the criteria and standards that are the
subject of the notice will be effective beginning on the first day of
the first month following
[[Page 57515]]
publication of this notice in the Federal Register. Any revised
criteria and standards will measure performance prospectively; that is,
any new criteria and standards in the notice will be applied only to
performance after the effective date listed on the notice.
It is not our intention to revise the criteria and standards that
will be used during the evaluation period once this information is
published in a Federal Register notice. However, on occasion, either
because of administrative action or statutory mandate, there may be a
need for changes that have a direct impact on the criteria and
standards previously published, or that require the addition of new
criteria or standards, or that cause the deletion of previously
published criteria and standards. If we must make these changes, we
will publish an amended Federal Register notice before implementation
of the changes. In all instances, necessary manual issuances will be
published to ensure that the criteria and standards are applied
uniformly and accurately. Also, as in previous years, this Federal
Register notice will be republished and the effective date revised if
changes are warranted as a result of the public comments received on
the criteria and standards.
The Medicare Prescription Drug, Improvement and Modernization Act
of 2003 (MMA) (Pub. L. 108-173) was enacted on December 8, 2003.
Section 911 of the MMA establishes the Medicare FFS Contracting Reform
(MCR) initiative that will be implemented over the next several years.
This provision requires that we use competitive procedures to replace
our current FIs and carriers with Medicare Administrative Contractors
(MACs). The MMA requires that we compete and transition all work to
MACs by October 1, 2011.
FIs and carriers will continue administering Medicare FFS work
until the final competitively selected MAC is up and operating. We will
continue to develop and publish standards and criteria for use in
evaluating the performance of FIs and carriers as long as these types
of contractors exist.
II. Analysis of and Response to Public Comments Received on FY 2006
Criteria and Standards
We received two comments in response to the September 23, 2005
Federal Register general notice with comment. All comments were
reviewed, but none necessitated our reissuance of the FY 2006 Criteria
and Standards. Comments submitted did not pertain specifically to the
FY 2006 Criteria and Standards.
III. Criteria and Standards--General
[If you choose to comment on issues in this section, please include
the caption ``CRITERIA AND STANDARDS--GENERAL'' at the beginning of
your comments.]
Basic principles of the Medicare program are to pay claims promptly
and accurately, and to foster good beneficiary and provider relations.
Contractors must administer the Medicare program efficiently and
economically. The goal of performance evaluation is to ensure that
contractors meet their contractual obligations. We measure contractor
performance to ensure that contractors do what is required of them by
statute, regulation, contract, and our directives.
We have developed a contractor oversight program for FY 2007 that
outlines the expectations of the contractor; measures the performance
of the contractor; evaluates the contractor's performance against those
expectations; and provides for appropriate contract action based upon
the evaluation of the contractor's performance.
As a means to monitor the accuracy of Medicare FFS payments, we
have established the Comprehensive Error Rate Testing (CERT) program
that measures and reports error rates for claims payment decisions made
by carriers and FIs. Beginning in November 2003, the CERT program
measures and reports claims payment error rates for each individual
carrier. FI-specific rates became available November 2004. These rates
measure not only how well contractors are doing at implementing
automated review edits and identifying which claims to subject to
manual medical review, but they also measure the impact of the
contractor's provider outreach/education, as well as the effectiveness
of the contractor's provider call center(s). We will use these
contractor-specific error rates as a means to evaluate a contractor's
performance.
Several times throughout this notice, we refer to the appropriate
reading level of letters, decisions, or correspondence that are mailed
or otherwise transmitted to Medicare beneficiaries from intermediaries
or carriers. In those instances, appropriate reading level is defined
as whether the communication is below the eighth grade reading level
unless it is obvious that an incoming request from the beneficiary
contains language written at a higher level. In these cases, the
appropriate reading level is tailored to the capacities and
circumstances of the intended recipient.
In addition to evaluating performance based upon our expectations
for FY 2007, we may also conduct follow-up evaluations throughout FY
2007 of areas in which contractor performance was out of compliance
with statute, regulations, and our performance expectations during
prior review years where contractors were required to submit a
Performance Improvement Plan (PIP).
We may also utilize Statement of Auditing Standards-70 (SAS-70)
reviews as a means to evaluate contractors in some or all business
functions.
In FY 2001, we established the Contractor Rebuttal Process as a
commitment to continual improvement of contractor performance
evaluation (CPE). We will continue the use of this process in FY 2007.
The Contractor Rebuttal Process provides the contractors an opportunity
to submit a written rebuttal of CPE findings of fact. Whenever we
conduct an evaluation of contractor operations, contractors have 7
calendar days from the date of the CPE review exit conference to submit
a written rebuttal. The CPE review team or, if appropriate, the
individual reviewer considers the contents of the rebuttal before the
issuance of the final CPE report to the contractor.
The FY 2007 CPE for intermediaries and carriers is structured into
five criteria designed to meet the stated objectives. The first
criterion, claims processing, measures contractual performance against
claims processing, accuracy and timeliness requirements, as well as
activities in handling appeals. Within the claims processing criterion,
we have identified those performance standards that are mandated by
legislation, regulation, or judicial decision. These standards include
claims processing timeliness, the accuracy of Medicare Summary Notices
(MSNs), the timeliness of intermediary and carrier redeterminations,
and the appropriateness of the reading level and content of
intermediary and carrier redetermination letters. Further evaluation in
the claims processing criterion may include, but is not limited to, the
accuracy of claims processing, the percent of claims paid with
interest, the accuracy of redeterminations, forwarding to and
effectuation of Qualified Independent Contractor (QIC) decisions, and
effectuation of administrative law judge (ALJ) decisions.
The second criterion, customer service, assesses the adequacy of
the service provided to customers by the contractor in its
administration of the Medicare program. The mandated standard in the
customer service criterion is the need to provide
[[Page 57516]]
beneficiaries with written replies that are responsive, that is, they
provide in detail the reasons for a determination when a beneficiary
requests this information, they have a customer-friendly tone and
clarity, and they are at the appropriate reading level. Further
evaluation of services under this criterion may include, but will not
be limited to, the following:
(1) Timeliness and accuracy of all correspondence both to
beneficiaries and providers; (2) monitoring of the quality of replies
provided by the contractor's telephone customer service representatives
(quality call monitoring);
(3) beneficiary and provider education, training, and outreach
activities; and (4) service provided by the contractor's customer
service representatives to beneficiaries and providers who come to the
contractor's facility (walk-in inquiry service).
The third criterion, payment safeguards, evaluates whether the
Medicare Trust Fund is safeguarded against inappropriate program
expenditures. Intermediary and carrier performance may be evaluated in
the areas of Medical Review (MR), Medicare Secondary Payer (MSP),
Overpayments (OP), and Provider Enrollment (PE). In addition,
intermediary performance may be evaluated in the area of Audit and
Reimbursement (A&R).
In FY 1996, the Congress enacted the Health Insurance Portability
and Accountability Act (HIPAA), Medicare Integrity Program, giving us
the authority to contract with entities other than, but not excluding,
Medicare carriers and intermediaries to perform certain program
safeguard functions. In situations where one or more program safeguard
functions are contracted to another entity, we may evaluate the flow of
communication and information between a Medicare FFS contractor and the
payment safeguard contractor. All benefit integrity functions have been
transitioned from the intermediaries and carriers to the program
safeguard contractors.
Mandated performance standards for intermediaries in the payment
safeguards criterion include the accuracy of decisions on SNF demand
bills and the timeliness of processing Tax Equity and Fiscal
Responsibility Act (TEFRA) target rate adjustments, exceptions, and
exemptions. There are no mandated performance standards for carriers in
the payment safeguards criterion. Intermediaries and carriers may also
be evaluated on any Medicare Integrity Program (MIP) activities if
performed under their agreement or contract.
The fourth criterion, fiscal responsibility, evaluates the
contractor's efforts to protect the Medicare program and the public
interest. Contractors must effectively manage Federal funds for both
the payment of benefits and the costs of administration under the
Medicare program. Proper financial and budgetary controls, including
internal controls, must be in place to ensure contractor compliance
with its agreement with HHS and CMS.
Additional functions reviewed under this criterion may include, but
are not limited to, adherence to approved budget, compliance with the
Budget and Performance Requirements (BPRs), and compliance with
financial reporting requirements.
The fifth and final criterion, administrative activities, measures
a contractor's administrative management of the Medicare program. A
contractor must efficiently and effectively manage its operations.
Proper systems security (general and application controls), Automated
Data Processing (ADP) maintenance, and disaster recovery plans must be
in place. A contractor's evaluation under the administrative activities
criterion may include, but is not limited to, establishment,
application, documentation, and effectiveness of internal controls that
are essential in all aspects of a contractor's operation, as well as
the degree to which the contractor cooperates with us in complying with
the Federal Managers' Financial Integrity Act of 1982 (FMFIA).
Administrative activities evaluations may also include reviews related
to contractor implementation of our general instructions and data and
reporting requirements.
We have developed separate measures for RHHIs in order to evaluate
the distinct RHHI functions. These functions include the processing of
claims from freestanding HHAs, hospital-affiliated HHAs, and hospices.
Through an evaluation using these criteria and standards, we may
determine whether the RHHI is effectively and efficiently administering
the program benefit or whether the functions should be moved from one
intermediary to another in order to gain that assurance.
In sections IV through VI of this notice, we list the criteria and
standards to be used for evaluating the performance of intermediaries,
RHHIs, and carriers.
IV. Criteria and Standards for Intermediaries
[If you choose to comment on issues in this section, please include
the caption ``CRITERIA AND STANDARDS FOR INTERMEDIARIES'' at the
beginning of your comments.]
A. Claims Processing Criterion
The claims processing criterion contains the following three
mandated standards:
Standard 1. Not less than 95.0 percent of clean electronically
submitted non-Periodic Interim Payment claims are paid within
statutorily specified timeframes. Clean claims are defined as claims
that do not require Medicare intermediaries to investigate or develop
them outside of their Medicare operations on a prepayment basis.
Specifically, the statute specifies that clean nonPeriodic Interim
Payment electronic claims be paid no earlier than the 14th day after
the date of receipt, and that interest is payable for any clean claims
if payment is not issued by the 31st day after the date of receipt.
Standard 2. Redetermination letters prepared in response to
beneficiary initiated appeal requests are written in a manner
calculated to be understood by the beneficiary. Letters must contain
the required elements as specified in Sec. 405.956.
Standard 3. All redeterminations must be concluded and mailed
within 60 days of receipt of the request, unless the appellant submits
documentation after the request, in which case the decision-making
timeframe is extended for 14 calendar days for each submission.
Because intermediaries process many claims for benefits under the
Part B portion of the Medicare Program, we also may evaluate how well
an intermediary follows the procedures for processing appeals of any
claims for Part B benefits.
Additional functions that may be evaluated under this criterion
include, but are not limited to, the following:
Accuracy of claims processing.
Remittance advice transactions.
Establishment and maintenance of a relationship with
Common Working File (CWF) Host.
Accuracy of redeterminations.
QIC case file requirements.
Accuracy and timeliness of processing appeals as set forth
in part 405, subpart I (Sec. 405.900 et seq.).
B. Customer Service Criterion
Functions that may be evaluated under this criterion include, but
are not limited to, the following:
Maintaining a properly programmed interactive voice
response system to assist with inquiries.
Performing quality call monitoring.
Training customer service representatives.
[[Page 57517]]
Entering valid call center performance data in the
customer service assessment and management system.
Providing timely and accurate written replies to
beneficiaries and providers that address the concerns raised and are
written with an appropriate customer-friendly tone and clarity; and
those written to beneficiaries are at the appropriate reading level.
Maintaining walk-in inquiry service for beneficiaries and
providers.
Conducting beneficiary and provider education, training,
and outreach activities.
Effectively maintaining an Internet Web site dedicated to
furnishing providers and physicians timely, accurate, and useful
Medicare program information.
Ensuring written correspondence is evaluated for quality.
C. Payment Safeguards Criterion
The Payment Safeguard criterion contains the following two mandated
standards:
Standard 1. Decisions on SNF demand bills are accurate.
Standard 2. TEFRA target rate adjustments, exceptions, and
exemptions are processed within mandated timeframes. Specifically,
applications must be processed to completion within 75 days after
receipt by the contractor or returned to the hospitals as incomplete
within 60 days of receipt.
Intermediaries may also be evaluated on any MIP activities if
performed under their Part A contractual agreement. These functions and
activities include, but are not limited to, the following:
Audit and Reimbursement
+ Performing the activities specified in our general instructions
for conducting audit and settlement of Medicare cost reports.
+ Establishing accurate interim payments.
Medical Review
+ Increasing the effectiveness of medical review activities.
+ Exercising accurate and defensible decision-making on medical
reviews.
+ Effectively educating and communicating with the provider
community.
+ Collaborating with other internal components and external
entities to ensure the effectiveness of medical review activities.
Medicare Secondary Payer
+ Accurately following MSP claim development and edit procedures.
+ Auditing hospital files and claims to determine that claims are
being filed to Medicare appropriately.
+ Supporting the Coordination of Benefits Contractor's efforts to
identify responsible payers primary to Medicare.
+ Supporting all the Medicare Secondary Payer Recovery functions.
+ Accurately reporting MSP savings.
Overpayments
+ Collecting and referring Medicare debts timely.
+ Accurately reporting and collecting overpayments.
+ Adhering to our instructions for management of Medicare Trust
Fund debts.
Provider Enrollment
+ Complying with assignment of staff to the provider enrollment
function and training the staff in procedures and verification
techniques.
+ Complying with the operational standards relevant to the process
for enrolling providers.
D. Fiscal Responsibility Criterion
We may review the intermediary's efforts to establish and maintain
appropriate financial and budgetary internal controls over benefit
payments and administrative costs. Proper internal controls must be in
place to ensure that contractors comply with their agreements with us.
Additional functions that may be reviewed under the fiscal
responsibility criterion include, but are not limited to, the
following:
Adherence to approved program management and MIP budgets.
Compliance with the BPRs.
Compliance with financial reporting requirements.
Control of administrative cost and benefit payments.
E. Administrative Activities Criterion
We may measure an intermediary's administrative ability to manage
the Medicare program. We may evaluate the efficiency and effectiveness
of its operations, its system of internal controls, and its compliance
with our directives and initiatives.
We may measure an intermediary's efficiency and effectiveness in
managing its operations. Proper systems security (general and
application controls), ADP maintenance, and disaster recovery plans
must be in place. An intermediary must also test system changes to
ensure the accurate implementation of our instructions.
Our evaluation of an intermediary under the administrative
activities criterion may include, but is not limited to, reviews of the
following:
Systems security.
ADP maintenance (configuration management, testing, change
management, and security).
Implementation of the Electronic Data Interchange (EDI)
standards adopted for use under HIPAA.
Disaster recovery plan and systems contingency plan.
Data and reporting requirements implementation.
Internal controls establishment and use, including the
degree to which the contractor cooperates with the Secretary in
complying with the FMFIA.
Implementation of our general instructions.
V. Criteria and Standards for Regional Home Health Intermediaries
(RHHIs)
[If you choose to comment on issues in this section, please include
the caption ``CRITERIA AND STANDARDS FOR RHHIs'' at the beginning of
your comments.]
The following three standards are mandated for the RHHI criterion:
Standard 1. Not less than 95.0 percent of clean electronically
submitted non-Periodic Interim Payment home health and hospice claims
are paid within statutorily specified timeframes. Clean claims are
defined as claims that do not require Medicare intermediaries to
investigate or develop them outside of their Medicare operations on a
prepayment basis. Specifically, the statute specifies that clean non-
Periodic Interim Payment electronic claims be paid no earlier than the
14th day after the date of receipt, and that interest is payable for
any clean claims if payment is not issued by the 31st day after the
date of receipt.
Standard 2. Redetermination letters prepared in response to
beneficiary initiated appeal requests are written in a manner
calculated to be understood by the beneficiary. Letters must contain
the required elements as specified in Sec. 405.956.
Standard 3: All redeterminations must be concluded and mailed
within 60 days of receipt of the request, unless the appellant submits
documentation after the request, in which case the decision-making
timeframe is extended for 14 calendar days for each submission.
We may use this criterion to review an RHHI's performance for
handling the HHA and hospice workload. This includes processing HHA and
hospice claims timely and accurately, properly paying and settling HHA
cost reports,
[[Page 57518]]
and accurately processing redeterminations of initial determinations
from beneficiaries, HHAs, and hospices.
VI. Criteria and Standards for Carriers
[If you choose to comment on issues in this section, please include
the caption ``CRITERIA AND STANDARDS FOR CARRIERS'' at the beginning of
your comments.]
A. Claims Processing Criterion
The claims processing criterion contains the following four
mandated standards:
Standard 1. Not less than 95.0 percent of clean electronically
submitted claims are processed within statutorily specified timeframes.
Clean claims are defined as claims that do not require Medicare
carriers to investigate or develop them outside of their Medicare
operations on a prepayment basis. Specifically, the statute specifies
that clean non-Periodic Interim payment electronic claims be paid no
earlier than the 14th day after the date of receipt, and that interest
is payable for any clean claims if payment is not issued by the 31st
day after the date of receipt.
Standard 2. Ninety-eight percent of MSNs are properly generated.
Our expectation is that MSN messages are accurately reflecting the
services provided.
Standard 3. Redetermination letters prepared in response to
beneficiary initiated appeal requests are written in a manner
calculated to be understood by the beneficiary. Letters must contain
the required elements as specified in Sec. 405.956.
Standard 4. All redeterminations must be concluded and mailed
within 60 days of receipt of the request, unless the appellant submits
documentation after the request, in which case the decision-making
timeframe is extended for 14 calendar days for each submission.
Additional functions that may be evaluated under this criterion
include, but are not limited to, the following:
Accuracy of claims processing.
Remittance advice transactions.
Establishment and maintenance of relationship with Common
Working File (CWF) Host.
Accuracy of redetermination decisions.
QIC case file requirements.
Accuracy and timeliness of processing appeals as set forth
in part 405, subpart I (Sec. 405.900 et seq.).
B. Customer Service Criterion
The customer service criterion contains the following mandated
standard: Replies to beneficiary written correspondence are responsive
to the beneficiary's concerns; are written with an appropriate
customer-friendly tone and clarity; and are written at the appropriate
reading level.
Contractors must meet our performance expectations that
beneficiaries and providers are served by prompt and accurate
administration of the program in accordance with all applicable laws,
regulations, and our general instructions.
Additional functions that may be evaluated under this criterion
include, but are not limited to, the following:
Maintaining a properly programmed interactive voice
response system to assist with inquiries.
Performing quality call monitoring.
Training customer service representatives.
Entering valid call center performance data in the
customer service assessment and management system.
Providing timely and accurate written replies to
beneficiaries and providers.
Maintaining walk-in inquiry service for beneficiaries and
providers.
Conducting beneficiary and provider education, training,
and outreach activities.
Effectively maintaining an Internet Web site dedicated to
furnishing providers timely, accurate, and useful Medicare program
information.
Ensuring written correspondence is evaluated for quality.
C. Payment Safeguards Criterion
Carriers may be evaluated on any MIP activities if performed under
their contracts. In addition, other carrier functions and activities
that may be reviewed under this criterion include, but are not limited
to the following:
Medical Review
+ Increasing the effectiveness of medical review activities.
+ Exercising accurate and defensible decision-making on medical
reviews.
+ Effectively educating and communicating with the provider
community.
+ Collaborating with other internal components and external
entities to ensure the effectiveness of medical review activities.
Medicare Secondary Payer
+ Accurately following MSP claim development/edit procedures.
+ Supporting the Coordination of Benefits Contractor's efforts to
identify responsible payers primary to Medicare.
+ Supporting all the Medicare Secondary Payer Recovery functions.
+ Accurately reporting MSP savings.
Overpayments
+ Collecting and referring Medicare debts timely.
+ Accurately reporting and collecting overpayments.
+ Compliance with our instructions for management of Medicare Trust
Fund debts.
Provider Enrollment
+ Complying with assignment of staff to the provider enrollment
function and training staff in procedures and verification techniques.
+ Complying with the operational standards relevant to the process
for enrolling suppliers.
D. Fiscal Responsibility Criterion
We may review the carrier's efforts to establish and maintain
appropriate financial and budgetary internal controls over benefit
payments and administrative costs. Proper internal controls must be in
place to ensure that contractors comply with their contracts.
Additional functions that may be reviewed under the Fiscal
Responsibility criterion include, but are not limited to, the
following:
Adherence to approved program management and MIP budgets.
Compliance with the BPRs.
Compliance with financial reporting requirements.
Control of administrative cost and benefit payments.
E. Administrative Activities Criterion
We may measure a carrier's administrative ability to manage the
Medicare program. We may evaluate the efficiency and effectiveness of
its operations, its system of internal controls, and its compliance
with our directives and initiatives.
We may measure a carrier's efficiency and effectiveness in managing
its operations. Proper systems security (general and application
controls), ADP maintenance, and disaster recovery plans must be in
place. Also, a carrier must test system changes to ensure accurate
implementation of our instructions.
Our evaluation of a carrier under this criterion may include, but
is not limited to, reviews of the following:
Systems security.
ADP maintenance (configuration management, testing, change
management, and security).
Disaster recovery plan/systems contingency plan.
Data and reporting requirements implementation.
Internal controls establishment and use, including the
degree to which the
[[Page 57519]]
contractor cooperates with the Secretary in complying with the FMFIA.
Implementation of the Electronic Data Interchange (EDI)
standards adopted for use under the Health Insurance Portability and
Accountability Act (HIPAA).
Implementation of our general instructions.
VII. Action Based on Performance Evaluations
[If you choose to comment on this section, please include the
caption ``ACTION BASED ON PERFORMANCE EVALUATIONS'' at the beginning of
your comments.]
We evaluate a contractor's performance against applicable program
requirements for each criterion. Each contractor must certify that all
information submitted to us relating to the contract management
process, including, without limitation, all files, records, documents
and data, whether in written, electronic, or other form, is accurate
and complete to the best of the contractor's knowledge and belief. A
contractor is required to certify that its files, records, documents,
and data are not manipulated or falsified in an effort to receive a
more favorable performance evaluation. A contractor must further
certify that, to the best of its knowledge and belief, the contractor
has submitted, without withholding any relevant information, all
information required to be submitted for the contract management
process under the authority of applicable law(s), regulation(s),
contract(s), or our manual provision(s). Any contractor that makes a
false, fictitious, or fraudulent certification may be subject to
criminal or civil prosecution, as well as appropriate administrative
action. This administrative action may include debarment or suspension
of the contractor, as well as the termination or nonrenewal of a
contract.
If a contractor meets the level of performance required by
operational instructions, it meets the requirements of that criterion.
When we determine a contractor is not meeting performance requirements,
we will use the terms ``major nonconformance'' or ``minor
nonconformance'' to classify our findings. A major nonconformance is a
nonconformance that is likely to result in failure of the supplies or
services, or to materially reduce the usability of the supplies or
services for their intended purpose. A minor nonconformance is a
nonconformance that is not likely to materially reduce the usability of
the supplies or services for their intended purpose, or is a departure
from established standards having little bearing on the effective use
or operation of the supplies or services. The contractor will be
required to develop and implement PIPs for findings determined to be
either a major or minor nonconformance. The contractor will be
monitored to ensure effective and efficient compliance with the PIP,
and to ensure improved performance when requirements are not met.
The results of performance evaluations and assessments under all
criteria applying to intermediaries, carriers, and RHHIs will be used
for contract management activities and will be published in the
contractor's annual Report of Contractor Performance (RCP). We may
initiate administrative actions as a result of the evaluation of
contractor performance based on these performance criteria. Under
sections 1816 and 1842 of the Act, we consider the results of the
evaluation in our determinations when--
Entering into, renewing, or terminating agreements or
contracts with contractors, and
Deciding other contract actions for intermediaries and
carriers (such as deletion of an automatic renewal clause). These
decisions are made on a case-by-case basis and depend primarily on the
nature and degree of performance. More specifically, these decisions
depend on the following:
+ Relative overall performance compared to other contractors.
+ Number of criteria in which nonconformance occurs.
+ Extent of each nonconformance.
+ Relative significance of the requirement for which nonconformance
occurs within the overall evaluation program.
+ Efforts to improve program quality, service, and efficiency.
+ Deciding the assignment or reassignment of providers and
designation of regional or national intermediaries for classes of
providers.
We make individual contract action decisions after considering
these factors in terms of their relative significance and impact on the
effective and efficient administration of the Medicare program.
In addition, if the cost incurred by the intermediary, RHHI, or
carrier to meet its contractual requirements exceeds the amount that we
find to be reasonable and adequate to meet the cost that must be
incurred by an efficiently and economically operated intermediary or
carrier, these high costs may also be grounds for adverse action.
VIII. Collection of Information Requirements
This document does not impose information collection and record
keeping requirements. Consequently, the Office of Management and Budget
need not review it under the authority of the Paperwork Reduction Act
of 1995 (44 U.S.C. 3501 et seq.).
IX. Response to Comments
Because of the large number of items of correspondence we normally
receive on Federal Register documents published for comment, we are
unable to acknowledge or respond to them individually. We will consider
all comments we receive by the date and time specified in the ``Comment
Date'' section of this notice, and, if we proceed with a subsequent
document, we will respond to the comments in the section entitled as
``Analysis of and Response to Public Comments Received on FY 2007
Criteria and Standards'' of that document.
Authority: Sections 1816(f), 1834(a)(12), and 1842(b) of the
Social Security Act (42 U.S.C. 1395h(f), 1395m(a)(12), and 1395u(b))
(Catalog of Federal Domestic Assistance Program No. 93.773,
Medicare--Hospital Insurance, and Program No. 93.774, Medicare--
Supplementary Medical Insurance Program)
Dated: June 22, 2006.
Mark B. McClellan,
Administrator, Centers for Medicare & Medicaid Services.
[FR Doc. E6-15991 Filed 9-28-06; 8:45 am]
BILLING CODE 4120-01-P