CMS RFQ: Third Party Administrator (TPA) of the Medicare Part D Coverage Gap Discount Program (CGDP)

Notice ID: RFQ1487029

“This contract defines the requirements for the Third Party Administrator (TPA) of the Medicare Part D Coverage Gap Discount Program (CGDP). Those functions include development, testing, implementation, operation, maintenance, and customer service necessary to meet the needs of CMS, pharmaceutical manufacturers, Part D sponsors, and contracted CMS personnel involved with the operation and administration of the Medicare Coverage Gap Discount Program, in accordance with the provisions of the legislation listed below.”

“Specific TPA Requirements:

  • 3.1 Connectivity with CMS Systems

The TPA Contractor shall establish communications through MDCN in order to facilitate transfer of data files between the TPA and CMS or its contractors. Additionally, the TPA shall establish connectivity with the Health Plan Management System (HPMS).

The TPA shall attend production calls with CMS and its contractors, and shall take a leadership role in all discussions involving payment portal modifications and report design that could impact the CGDP invoicing, reconciliation and disputes functions.

  • 3.2 Connectivity between TPA and Part D Sponsors and Manufacturers

The TPA shall establish and administer Electronic Data Interchange (EDI) protocols and assist pharmaceutical manufacturers and Part D sponsors in establishing connectivity to submit electronic data. The TPA shall maintain a current database of all entities submitting data, type of data being submitted, connectivity type (i.e., SFTP, Connect:Direct), submitter/contract linkage and/or relationship and current contact information, at a minimum. The TPA shall utilize an effective and efficient communication strategy to collect contact data…

  • 3.3 CGDP Report Creation and Distribution

The TPA shall have the capacity to retrieve reports from a mainframe and CMS AWS cloud enclave environment parse a single file into multiple reports, and deliver the reports to the appropriate pharmaceutical manufacturer or Part D sponsor secure electronic mailbox or alternative delivery mechanism maintained by the TPA. Examples of reports transmitted to the TPA via mainframe, and distributed by the TPA include: Quarterly Invoice Reports, Dispute Resolution Reports, Annual CGDP Reconciliation Reports, and other one-time ad hoc reports distributed at the direction of CMS…

  • 3.4 Customer Support Center

The TPA shall serve as the single point of contact for all pharmaceutical manufacturer and Part D sponsor plan questions concerning TPA functions, invoices, disputes, appeals, audits and data associated with the CGDP. The contractor shall facilitate payment between parties to ensure invoiced amounts are paid…

  • 3.5 Standard Reporting and Ad Hoc Data Analysis

The TPA Contractor shall perform analysis of information and reports. This shall include analysis of information and data received through performance of the customer support task, as well as analysis of production data such as quarterly invoices, dispute files, and payment compliance. This analysis will enable the contractor to proactively interact with pharmaceutical manufacturers, Part D sponsors, and CMS in identifying potential issues and problems, trends, forecasting, potential topics for targeted training, poorly performing organizations, identification of data anomalies and recommended solutions to those issues…

  • 3.6 Facilitate Audit of the CGDP data by Manufacturers or their Designees

The contractor shall facilitate audits conducted by manufacturers or their designees of the CGDP by developing statistically representative random sample of invoiced claims, providing space and computer resources on-site at the TPA for auditors to conduct their work, answering auditor’s questions while on- site, and preparing a response to any formal audit findings, subject to CMS review and approval. The TPA shall provide the random sample for CMS approval prior to distributing the sample data to the auditors. The TPA shall provide the sample in two ways: the first with the data elements that will be provided to the auditors as specified in the Manufacturer’s Agreement, and the second with all PDE data elements and any additional data regarding the invoicing and dispute disposition, as specified by CMS. The TPA shall be responsible for the data analysis associated with manufacturer audits and shall be responsible for letters issued by CMS after the audit occurs.

  • 3.7 Website Development and Support

The contractor shall provide adequate staffing to maintain a Web site that provides operational information and guidance to pharmaceutical manufacturers and Part D sponsors…”

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