CMS Sources Sought: Risk Adjustment Data Validation Hearing Officer Appeals Support

Notice ID: SSN200934

“This is a SOURCES SOUGHT NOTICE (“Notice”) to determine the availability of small businesses on the GSA Professional Services Schedule that have the capability to support the Centers for Medicare & Medicaid Services’ (“CMS”) Office of Hearings to implement and manage the Risk Adjustment Data Validation (“RADV”).”

“The Contractor must be capable of supporting the CMS Hearing Officer in the development and implementation of the Hearing Officer RADV appeals process.  Such support shall include, but is not limited to, review of appeal documentation, briefs and medical records; communicating and scheduling pre-hearing, briefing and hearing proceedings; providing coding, medical and legal recommendations to the Hearing Officer through comprehensive memoranda; and performing payment error calculations as required with comprehensive and detailed breakdown of such calculations.”

The descriptions below highlight the major tasks that the Contractor must provide.  CMS expects that each Major Task will require key staff types devoted to each activity.

The case management tasks include:

  • Developing, implementing, and overseeing a timely and efficient initial intake and review of MA organizations’ requests for hearing regarding the RADV Audit Reconsideration Decisions;
  • Organizing RADV appeals into categories for the Hearing Officer in order to facilitate efficient and timely adjudication…

The Coding Professional’s tasks include:

  • Reviewing Reconsideration Determinations, MA organizations’ justifications, arguments within the parties’ briefs and the enrollees’ medical records for appealed CMS-HCCs, then
  • Preparing a report that contains coding analysis and conclusions.

The Medical Professional’s tasks include:

  • Reviewing Reconsideration Determinations, MA organizations’ justifications, arguments within the parties’ briefs and the enrollees’ medical records for appealed CMS-HCCs, then…

Read more here.

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