Medicare Administrative Contractor (MAC) Services - Medicare Parts A & B (Medicare Fee-for-Service) - Jurisdiction G (JG)

Background
The Centers for Medicare & Medicaid Services (CMS) is issuing this contract to obtain a Medicare Administrative Contractor (MAC) to provide specified health insurance benefit administration services, including Medicare claims processing and payment services, in support of the Medicare fee-for-service (FFS) program.

The mission of CMS is to ensure health care security for beneficiaries, which this contract aims to support by fostering excellence in the design and administration of CMS’ programs. The Medicare program serves eligible individuals aged 65 and over, certain individuals eligible for disability benefits, and those with end-stage renal disease. It operates under two primary systems: the traditional Medicare FFS program and privately sponsored Medicare Advantage plans.

Work Details
The Contractor will perform numerous functions including: managing claims-related activities, establishing relationships with healthcare providers, performing standard editing on claims, calculating payment amounts, enrolling new providers, conducting redeterminations on appeals of claims, operating a Provider Customer Service Program (PCSP), responding to inquiries from providers and beneficiaries, and making coverage decisions for new procedures and devices.

The Contractor must comply with applicable laws, regulations, Medicare manuals, and CMS requirements to ensure the financial integrity of the Medicare program. Specific tasks include:
1. Claims Processing: Receive and control Medicare claims from institutional and professional providers.
2. Payment Management: Calculate payment amounts and arrange remittance.
3. Provider Enrollment: Enroll new providers into the system.
4. Customer Service: Operate a PCSP that educates providers about billing procedures.
5. Compliance: Ensure adherence to CMS guidelines and respond to complex inquiries.

Period of Performance
The period of performance for this contract will be defined in accordance with CMS requirements but typically spans multiple years as it involves ongoing administrative functions.

Place of Performance
The contract will be performed within the designated jurisdiction G which includes specific states as outlined by CMS.