[Federal Register Volume 60, Number 159 (Thursday, August 17, 1995)]
[Notices]
[Pages 42888-42899]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 95-20317]



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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Statement of Organization, Functions, and Delegations of 
Authority; Substructure for the Bureau of Program Operations

    Part F of the Statement of Organization, Functions, and Delegations 
of Authority for the Department of Health and Human Services, Health 
Care Financing Administration (HCFA), (Federal Register, Vol. 59, No. 
60, pp. 14648-14654, dated Tuesday, March 29, 1994, and Federal 
Register, Vol. 60, No.12, pg. 3869, dated Thursday, January 19, 1995) 
is amended to reflect a change to the subordinate structure of the 
Bureau of Program Operations (BPO).
    BPO is streamlining their organization by eliminating one entire 
organizational layer and realigning functions that supports the bureau 
in moving toward and into the Medicare Transaction System.
    The specific amendments to part F are described below:
    Section F.10.D., Health Care Financing Administration, Associate 
Administrator for Operations and Resource Management (FL) 
(Organization), paragraphs 4.a. through g. and all the associated 
subparagraphs are deleted and replaced with the following new 
organizational structure and administrative codes:
    4. Bureau of Program Operations (FLG)

a. Management & Program Support Staff (FLG-1)
b. Office of Analysis and Systems (FLG1)
    (1) Analysis (FLG11)
    (2) Operational Systems (FLG12)
    (3) Systems Testing (FLG13)
    (4) Systems Design (FLG14)
c. Office of Benefits Integrity (FLG2)
    (1) Medical Review (FLG21)
    (2) Program Integrity (FLG22)
    (3) Audit/CMP (FLG23)
    (4) Overpayment & MSP Collections (FLG24)
d. Office of Program Requirements (FLG3) 

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    (1) Institutional Claims Processing Requirements (FLG31)
    (2) Practitioner Claims Processing Requirements (FLG32)
    (3) Supplier Claims Processing Requirements (FLG33)
    (4) Standards Setting (FLG34)
    (5) Provider Enrollment (FLG35)
    (6) Benefit Coordination (FLG36)
e. Office of Contract Administration (FLG4)
    (1) Acquisitions & Contracts (FLG41)
    (2) Financial Management (FLG42)
    (3) Transition Management (FLG43)
    (4) Contract Management (FLG44)
    (5) Planning (FLG45)
f. Office of Customer Communications (FLG5)
    (1) Appeals (FLG51)
    (2) Entitlement & Premium Billing (FLG52)
    (3) Issuances (FLG53)
    (4) Medicare Customer Assistance (FLG54)
    (5) Communications (FLG55)
g. Medicare Transaction System Initiative Task Force (FLG6)
    (1) Medicare Transaction System Quality Assurance (FLG61)
    (2) Medicare Transaction System Development (FLG62)
    (3) Medicare Transaction System Program Planning & Needs Analysis 
(FLG63)

    Section F.20.D, Health Care Financing Administration Associate 
Administrator for Operations and Resource Management (FL) (Functions), 
paragraphs 4.a. through g. and all the associated subparagraphs are 
deleted and replaced with the following new functional statements and 
administrative codes:

a. Management & Program Support Staff (FLG-1)

     Plans and directs a comprehensive bureau-wide human 
resource management program including manpower selection and placement, 
organizational analysis, training and employee development (including 
ADP and Medicare program related training), position control, manpower 
utilization, employee counseling, equal employment opportunity, and 
labor relations activities.
     Plans, directs, and coordinates bureau-wide employee 
appraisal programs including SES performance monitoring programs and 
the administration of mandatory performance award system.
     Plans and manages the bureau's financial management 
program, interprets administrative budgetary policies and limitations, 
and issues bureau-wide guidelines and instructions for budget 
formulation and execution.
     Executes the budget through the issuance of staff and 
dollar controls, budget allowances for administrative expenditures, and 
employee ceilings to BPO sub-components.
     Plans and monitors all BPO administrative contracts and 
procurement and conducts management evaluations to assure the 
effectiveness of the bureau's overall financial operations.
     Directs the bureau's ADP activities which includes 
providing technical assistance to bureau components in mainframe and 
microcomputer applications, developing BPO automation strategy based on 
long-term needs and new initiatives, identifying bureau ADP needs and 
requirements, and coordinating with the Bureau of Data Management and 
Strategy the necessary implementation activities.
     Serves as a focus for information and analysis to support 
both short and long-range planning for the bureau, identifying trends 
in the findings of external monitoring organizations (i.e, the General 
Accounting Office) as well as internal reviews. Recommends changes in 
operating procedures, policies, strategies, and organizational 
structure as appropriate.
     Conducts studies and analyses of the bureau's work 
processes and procedures, workload and production data, material and 
staff resources, budgetary data and expenditures trends, and physical 
layout. Recommends changes in operating procedures, policies, 
strategies, and organizational structure as appropriate.
     Develops and implements all bureau programs and 
administrative delegations of authority and serves as a focal point for 
all delegations of authority issues affecting the bureau. Serves as the 
focal point in leading negotiations with other HCFA components to 
resolve conflicts over central or regional office responsibilities.
     Serves as the bureau's primary source for management 
consultation and advice on management policies and issues including 
highly sensitive and complex actions involving inter-bureau 
coordination. Develops and implements bureau-wide management policies.

b. Office of Analysis and Systems (FLG1)

     Provides requirements and specifications for the design, 
development, and maintenance of reporting and information management 
systems that generate data reflecting on Medicare program operations.
     Identifies reporting and information needs for data 
relating to Medicare contractor operations and initiates appropriate 
action for establishing or modifying the reporting and information 
systems to satisfy these needs.
     Analyzes a broad range of information, including computer 
stored data, on operations performed in support of the Medicare 
program; prepares interpretive reports and recommendations on findings 
to internal bureau components for purposes of conducting program and 
performance evaluations.
     Provides overall support to other staff in analyzing and 
interpreting program and operational data to better understand the 
program.
     Provides requirements and specifications for the design, 
development, and management at the national level, activities required 
to enhance systems for improvement of the Medicare eligibility systems, 
Part A and Part B claims processing systems, and the Medicare program 
database.
     Provides direction and guidance to HCFA staff (central 
office and regional) on improving contractor systems.
     Prepares systems plans and develops policies for the 
design, implementation, and evaluation of shared systems and 
standardized modules for use by Medicare carriers, intermediaries, and 
hosts.
     Directs the design, development testing, and 
implementation of innovative system enhancements to the Common Working 
File (CWF) shared claims processing systems resulting in improvements 
to the national Medicare claims payment process.
     Provides requirements and specifications for the 
development, implementation, execution, and monitoring of a procedure 
to provide ongoing testing of national claims processing and 
information system to detect flaws in the operation of software, 
hardware, and related operations.
     Provides requirements and specifications for the 
development and implementation of systems that provide for the creation 
and maintenance of databases and test files that are required to 
conduct comprehensive system acceptance testing of a national claims 
processing and information system.

(1) Analysis (FLG11)

     Provides requirements and specifications for the design, 
establishment, and maintenance of reporting and information management 
systems that generate data reflecting on Medicare program operations.
     Reviews contractors' reporting systems for consistency and 
the ability to transmit the required information and 

[[Page 42890]]
prepares the appropriate reporting requirements.
     Develops the specifications for an automated operational 
data system for Medicare.
     Prepares recurring reports on the status and trends in 
program administration and operational effectiveness.
     Provides technical assistance to regional offices and 
contractors on reporting requirements.
     Identifies reporting and information needs for data 
relating to Medicare contractor operations and initiates appropriate 
action for establishing or modifying the reporting and information 
systems to satisfy these needs.
     Analyzes a broad range of information, including computer 
stored data, on operations performed in support of the Medicare 
program; prepares interpretive reports and recommendations for the 
findings to other bureau components for purposes of conducting program 
and performance evaluations.
     Provides overall support to other staff in analyzing and 
interpreting program and operational data to better understand the 
program.
     Develops and publishes national reports on Medicare 
utilization patterns by procedure, beneficiary, etc.
     Analyzes patterns to determine contractor differences, 
changes in patterns, relationships between procedures, etc.
     Serves as the bureau focal point for support and liaison 
with other HCFA and non-HCFA components involved in data and 
information analyses.
     Utilizes the National Claims History Database to analyze 
and compare utilization patterns and to assess national trends in the 
provision of care to the Medicare population.
     Uses statistical databases and applications to analyze, 
evaluate, and make recommendations towards improving program 
operations, including operational efficiency.
     Provides statistical support to program studies and to 
analytical studies throughout the bureau.
     Evaluates and monitors proposals for new analytic methods 
to identify fraud, abuse and over utilization from claims data 
(Medicare Parts A and B).
     Responds to ad-hoc data requests for management 
information data.
     Acts as a liaison with the Bureau of Data Management and 
Strategy staff to enhance data available to BPO components.
     Directs workgroups to promote the continuous improvement 
in the use of data to conduct effective analysis in support of BPO 
component activities.
     Develops procedures and requirements for data analysis in 
the Medicare Transaction System environment.

(2) Operational Systems (FLG12)

     Prepares systems plans and develops policies for the 
design, implementation, and evaluation of shared systems and 
standardized modules for use by Medicare carriers, intermediaries, and 
hosts.
     Directs the design, development testing and implementation 
of innovative system enhancements to the Common Working File (CWF) 
shared claims processing systems resulting in improvements to the 
national Medicare claims payment process.
     Evaluates HCFA-wide systems plans for their impact on 
functions related to Part A and Part B of Medicare.
     Integrates systems changes within the framework of HCFA 
policies, goals, and objectives in an efficient and cost effective 
manner and coordinates system changes with other HCFA components, the 
Social Security Administration, HCFA regional offices, provider groups, 
and other affected organizations.
     Provides direction to the national CWF Maintenance 
Contractor and establishes priorities and schedules for all changes to 
CWF software and procedures and monitors progress in the release of 
these changes to all CWF users.
     Conducts and reviews national system impact analysis 
assessments relating to Medicare legislative mandates and oversees 
development of CWF specifications for national implementation of 
mandates.
     Develops and controls activities associated with the 
development of standard systems and standard modules and assists other 
HCFA components in preparing contract modifications associated with 
standard systems activities.
     Develops, monitors, and evaluates budgets and the budget 
forecasts for CWF, shared systems, and other contractor based 
operations including participation in long-range procurement planning 
support to procurement officials.
     Develops comprehensive systems security instructions in 
the Medicare Intermediary and Carrier Manuals.
     Provides regional offices with methods of reviews of 
contractor safeguards which include providing checklists for such 
initiatives as contingency planning and safeguarding the integrity of 
the Internal Revenue Service data used in the Medicare Secondary Payer 
data match and applying internal control sampling techniques to make 
sure that reviews have been performed adequately.
     Prepares quarterly listings of all significant tasks for 
carriers and intermediaries with special emphasis on those involving 
standard systems maintenance.

(3) Systems Testing (FLG13)

     Develops, implements, executes, and monitors a procedure 
to provide ongoing testing of national claims processing and 
information system to detect flaws in the operation of software, 
hardware, and related operations.
     Develops and implements systems that provide for the 
creation and maintenance of databases and test files that are required 
to conduct comprehensive system acceptance testing of a national claims 
processing and information system.
     Develops system test designs and test requirements for 
accomplishing system testing (hardware and software, etc.).
     Designs, develops, and maintains system software to 
accomplish testing requirements and processes.
     Performs system analyses and studies to develop testing 
strategies, procedures, and methodologies.
     Develops requirements and monitors implementation of 
corrective action plans for claims processing and information system 
that have failed to meet HCFA system testing requirements.
     Develops processes to monitor the implementation of new 
changed hardware and software that impact HCFA's claims processing and 
information system.
     Provides training and technical guidance to regional 
office and contractor staffs for implementing and operating national 
programs for assessing system testing activities.
     Consults and maintains working relations with contractors, 
HCFA components, and outside organizations for effective interchange of 
information and resolution of problems.
     Plans, develops, tests, and maintains a system to support 
Medicare claim and remittance electronic standardization enforcement 
and other front-end system testing activities.

(4) Systems Design (FLG14)

     Designs, develops, and manages, at the national level, 
activities required to enhance systems for improvement of the Medicare 
eligibility systems, Part A and Part B claims processing systems, and 
the Medicare program database.

[[Page 42891]]

     Provides direction and guidance to HCFA staff (central 
office and regional) on improving contractor systems.
     Designs, develops, and manages at the national level 
activities required to support the acquisition, establishment, and 
operation of the operating sites for the Medicare Transaction System 
(MTS).
     Coordinates and plans for the establishment of a test 
facility to ensure the system fully meets expectations of customers.
     Plans, develops, establishes, and maintains the processes 
necessary to manage all levels of change to the MTS.
     Plans, coordinates, and supports activities necessary to 
support the ongoing development and maintenance of system and program 
requirements for the MTS.
     Plans, supports, and participates in system activities to 
support transition to MTS.
     Serves as a technical specialist in the data 
telecommunications field and performs a broad variety of systems, 
software and hardware related tasks for major networks related to HCFA/
BPO's nationwide Medicare claims processing telecommunications 
networks.
     Plans, designs, organizes, and leads studies to develop 
long-range Medicare operational systems telecommunications strategies 
and advises senior program managers on applying advances in 
telecommunications technologies to the Medicare operational systems.

c. Office of Benefits Integrity (FLG2)

     Oversees the administration of Medicare program audit and 
payment management, benefit integrity, Medicare Secondary Payer (MSP), 
other overpayment collections, and medical review.
     Plans and develops methods to improve and enhance the 
audit and payment management functions and makes recommendations for 
improvements in the management of the audit program. Analyzes 
regulations, executive orders, policies, and legislative proposals and 
assesses their financial impact on the audit budget.
     Develops, implements, and maintains programs and systems 
to ensure that Medicare benefits are paid within the meaning of 
applicable law, regulations, and program policy and to ensure that 
internal or external allegations of fraudulent or abusive behavior are 
promptly acknowledged, developed, and disposed of including referral to 
the Office of Inspector General.
     Directs the development and issuance of specifications, 
requirements, procedures, forms, and instructional material to 
implement and maintain operational systems for Part A and Part B 
medical review and utilization analysis.
     Develops the national budget for intermediary and carrier 
payment safeguard activities, linking programmatic expectations with 
funding requirements and available resources. Implements new 
legislation impacting on payment safeguard processes and/or Medicare 
covered services.
     Supports MSP litigation and post pay activities.
     Reviews regional office and contractor performance in 
determining the correct amount of provider, physician, and supplier 
overpayments and assists contractors in negotiations related to the 
acceptability of techniques for determining the amount of an 
overpayment and the methods of recovery.
     Prepares cases when compromises are not appropriate and 
overpayments are collectable and assists the HCFA Claims Collection 
Officer in preparing such cases for disposition.
     Prepares manual instructions concerning the procedures for 
the recovery of provider, physician, and supplier overpayments.
     Designs, implements, and maintains a Medicare overpayment 
tracking system.
     Conducts in-depth evaluations of selected programmatic 
areas to determine whether established policy and operational criteria 
are effectively and accurately met.
     Develops and implements requirements for payment safeguard 
activities in the Medicare Transaction System environment.

(1) Medical Review (FLG21)

     Directs the development and issuance of specifications, 
requirements, procedures, forms, and instructional material to 
implement and maintain operational systems for carrier and fiscal 
intermediary medical review and utilization analysis.
     Reviews proposed payment and coverage policy and 
legislative proposals to evaluate the operational impact on the Medical 
Review and Utilization Review (MR/UR) program. Implements new 
legislation affecting MR/UR and develops program safeguards for new and 
revised procedures.
     Oversees and evaluates contractor development and 
implementation of local medical review policy and procedures. Provides 
support to contractor medical directors and develop tools and 
instructions that enhance the consistency local MR policy. Coordinates 
and generally oversees the Carrier Advisory Committee activities.
     Assists with the development of contractor performance 
standards to promote improvement and assess the effectiveness of the 
contractor's MR/UR program.
     Provides technical support and assistance to bureau, other 
HCFA, and non-HCFA components. Serves as liaison with representatives 
of the health care industry to obtain expert input, promote 
understanding of the MR/UR program, and to ensure that HCFA's processes 
are compatible with health practices.
     Recommends legislative, regulatory, and programmatic 
changes to implement utilization controls in problematic areas.
     Develops the national budget for intermediary and carrier 
medical review activities, linking programmatic expectations with 
funding requirements.
     Develops and implements procedures and requirements for 
medical review procedures in the Medicare Transaction System 
environment.
     Participates in the development of analytical studies, 
tools, methodologies, etc., to assist in identifying patterns and 
trends in health care utilization that indicate over utilization or 
abuse.

(2) Program Integrity (FLG22)

     Develops, implements, and maintains programs and systems 
to ensure that Medicare benefits are paid within the meaning of 
applicable law, regulations, and program policy.
     Develops, implements, and maintains programs and systems 
to ensure that internal or external allegations of fraudulent or 
abusive behavior against the Medicare program are promptly 
acknowledged, developed and corrective action taken including referral 
to Office of Inspector General.
     Coordinates the development, budgeting, and 
institutionalization of Medicare dedicated program integrity units in 
Medicare carriers and fiscal intermediaries and monitors their 
activities. Develop regulations, legislative proposals, contract 
amendments, and operating procedures for these units.
     Plans, conducts, and evaluates studies and recommends 
actions aimed at short and long-range improvements in methods and 
procedures, legislative and policy proposals to prevent and detect 
fraud, abuse, waste, and other violations of billing requirements of 
the Medicare program. 

[[Page 42892]]

     Provides bureau liaison with the Office of Inspector 
General, the Federal Bureau of Investigations, and the Department of 
Justice on program integrity issues, particularly on fraud and abuse 
issues and to improve the detection, development, and referral of fraud 
cases. Prepares and assists in preparation of reports to Congress. 
Develops and monitors relationships between Medicare contractors, and 
the State, local and private organizations, which are responsible for 
the detection and prevention of health care fraud including Medicaid 
State Agencies and fraud units. Ensures sharing of fraud information.
     Directs the development of analytical studies, tools, and 
other methodologies, etc., to detect potential fraudulent and abusive 
practices and patterns of over utilization.
     Develops procedures and requirements for program integrity 
activities in Medicare Transaction System environment.
     Issues national Medicare fraud alerts to notify 
contractors and public of fraudulent schemes. Coordinates at national 
level the review of proposed settlements negotiated by Office of the 
Inspector General, AUSA.

(3) Audit/CMP (FLG23)

     Analyzes regulations, executive orders, policies, and 
legislative proposals and assesses their financial impact on the audit 
budget. Develops the plan, necessary audit programs, guidelines, and 
instructions for the implementation of current and future legislation, 
regulations, and court orders.
     Plans and develops methods to improve and enhance the 
audit function and makes recommendations for improvements in management 
of the audit program. This includes the identification and 
implementation of ADP programs in the desk review, audit, and 
settlement activities.
     Develops rationale for the audit and payment management 
portion of the current and future national contractor budgets; monitors 
return ratios for provider audits to assure maximum return on 
investment expenditures.
     Reviews and analyzes Contractor Auditing and Settlement 
Reports to determine the effectiveness of contractor audit and payment 
performance and compliance with established audit guidelines, 
priorities, funding limitations, and workload objectives.
     Researches and responds to all Office of Inspector General 
and General Accounting Office reimbursement and financial audit reports 
and studies. Prepares position papers and reports offering alternative 
methods of resolution.
     Analyzes System Tracking for Audit and Reimbursement 
(STAR) data to assess effectiveness of audit policy and procedures and 
contractors compliance with such policy and procedures.
     Evaluates contractor requests for supplemental audit and 
payment management funding at the current operating budget level and 
makes recommendations based on available funding and defined program 
objectives.
     Develops, tests, and updates desk reviews, audit 
guidelines, and audit programs for use by the intermediaries to ensure 
that program objectives are achieved. Maintains contact with fiscal 
intermediaries through the regional office for resolution of audit 
problems.
     Reviews and evaluates existing audit and payment revisions 
with other components to resolve current and prevent potential 
problems. Analyzes and comments on proposed policy revisions, 
regulations, and legislation regarding provider payments.
     Plans, monitors, reports on, and develops guidelines for 
implementation of legislative special audit projects; e.g., the Wage 
Data Survey mandated by Section 4004 of OBRA and the implementation of 
the Capital Prospective Payment System.
     Manages the successful implementation of various 
negotiated agreements, court orders, special project activities, and 
Blue Cross/Blue Shield Association provider audit activities.
     Establishes audit protocols, priorities, and procedures 
for all intermediaries to follow in utilizing their audit resources.
     Assures optimum use of audit resources through the ADP 
processes.
     Directs the resolution of provider appeals assigned to the 
bureau. Analyzes and summarizes the payment issues and recommends a 
course of action.
     Develops guidelines and procedures for identifying 
appropriate civil monetary penalty cases under provisions for which 
HCFA has authority.
     Works with contractors and regional offices to document 
and develop specific cases.
     Oversees final adjudication of cases and collection of 
penalties.
     Negotiates settlement and compromises of selected penalty 
cases.
     Develops procedures and requirements for audit and 
reimbursement activities in Medicare Transaction System environment.

(4) Overpayment & MSP Collections (FLG24)

     Directs the nationwide administration of the institutional 
and physician/supplier (provider) payment recovery activity.
     Develops regulations, policies, procedures, guidelines, 
and recommendations for regional offices and HCFA contractors to assure 
timely and accurate provider overpayment identification, interest 
assessment, collection, and reduction of incidences of overpayment.
     Assures that the accounting practices, recovery 
procedures, and collection activities of regional offices and 
contractors properly and sufficiently implement (with respect to 
providers) the overpayment recovery policies, procedures, and 
regulations of HCFA, the Department of Health and Human Services, the 
General Accounting Office, the Department of Justice, and all 
applicable Federal statutes.
     Directs regional offices and contractors in determining 
the correct amount of provider, physician, and supplier overpayments 
and assists contractors in negotiations related to the acceptability of 
techniques for determining the amount of an overpayment and the methods 
of recovery.
     Prepares cases when compromises are not appropriate and 
overpayments are collectable and assists the HCFA Claims Collection 
Officer in preparing such cases for disposition.
     Prepares manual instructions concerning the procedures for 
the recovery of provider, physician, and supplier overpayment.
     Designs, implements, and maintains a Medicare overpayment 
tracking system.
     Develops procedures and provides training and assistance 
to regional offices for the review and evaluation of the institutional 
provider, physician, supplier, and beneficiary overpayment recovery and 
third party systems.
     Enforces Medicare Secondary Payer (MSP) provisions and 
supports MSP litigation and post pay activities. Monitors regional 
office and contractor operations on negotiation, waiver, and compromise 
of liability settlements where Medicare has a claim for recovery of 
prior conditional payments.
     Directs, oversees, and manages the contract for IRS/HCFA/
SSA data match activities. Oversees contractor activities for demands 
and collection of mistaken payments identified by data match.
     Oversees regional office and contractor identification of 
liability 

[[Page 42893]]
situations where Medicare has an interest in collection of monies paid 
on behalf of a Medicare beneficiary.
     Develops procedures and requirements for MSP and other 
overpayment activities in Medicare Transaction System environment.
     Coordinates and cooperates with medical review, audit, and 
program integrity units on use of overpayment recovery as a payment 
safeguard tool and to coordinate relationship between established 
overpayments and fraud cases.

d. Office of Program Requirements (FLG3)

     Develops, issues, and administers the specifications, 
requirements, methods, standards, procedures, and budget guidelines for 
Medicare claims processing related activities, including detailed 
definitions of the relative responsibilities of providers, contractors, 
HCFA, other third-party payers, and the beneficiaries of the Medicare 
program.
     Develops specifications and recommends budget necessary 
for more effective methods to process Medicare claims.
     Develops and maintains standards, including forms and 
electronic formats, used by contractors to process claims.
    Represents the Medicare program before the health care industry 
with regard to standards for administrative health care transactions.
     Develops and implements requirements for provider 
enrollment in the Medicare program and assures the safeguard of program 
payments through effective enrollment processes and procedures.
     Ensures effective program compliance in areas related to 
Medicare claims processing and provider enrollment. Implements and 
manages requirements related to prohibited physician referrals and 
provider billings resulting from prohibited referrals.
     Develops and implements procedures for capturing 
information related to Medicare Secondary Payer situations and Medigap 
insurance to insure appropriate program payment and effective 
coordination of claims information with other insurers.
     Reviews and evaluates the processes and procedures used in 
the receipt, review, and payment/denial of Medicare claims.
     Recommends alternatives to existing processes and 
procedures, as well as, methods of improvement.
     Manages experiments that incorporate proposed alternatives 
to existing processes and procedures.
     Coordinates modifications to existing operational 
procedures, contracts, reporting mechanisms, and related materials as 
required.
     Identifies vulnerabilities in Medicare claims processing 
requirements and implements instructions and guidelines for 
safeguarding program expenditures (administrative and benefit).
     Conducts in-depth evaluations of selected programmatic 
areas to determine whether established policy and operational criteria 
are effectively and accurately met.
     Maintains liaison with beneficiaries, providers, 
contractors, and other partners for purposes of ensuring that 
continuous improvements are made to HCFA processes and that the 
interests of customers and partners are considered.

(1) Institutional Claims Processing Requirements (FLG31)

     Develops and issues specifications, requirements, 
procedures, and instructional material to process claims from Medicare 
institutional providers and defines their applications to these 
providers (hospitals, skilled nursing facilities, home health agencies, 
hospices, rural health clinics, comprehensive outpatient rehabilitation 
facilities, End Stage Renal Disease facilities) and Medicare 
contractors.
     Develops and issues instructions for, as well as monitors, 
implementation of institutional provider pricers.
     Develops applicable bill processing edits for contractors 
and the Common Working File (CWF) processing of Medicare provider 
claims and works with the Office of Analysis and Systems to implement 
these edits at contractor and CWF sites.
     Identifies vulnerabilities in Medicare claims processing 
requirements and implements instructions and guidelines for 
safeguarding program expenditures (administrative and benefit).
     Maintains the contractor/provider instructional manuals 
including CWF interface instructions for processing claims from 
Medicare institutional providers.
     Implements new legislation impacting on the provider 
payment process.
     Reviews proposed policy, reimbursement, and legislative 
proposals to evaluate the operational impact on claims processing 
operations, including the development of cost estimates for the 
implementation of such proposals.
     Maintains liaison with representatives of the health care 
industry to ensure that HCFA processes are compatible with provider 
administration practices.
     Maintains liaison with beneficiaries, providers, 
contractors, and other partners for purposes of ensuring that 
continuous improvements are made to HCFA processes and that the 
interests of customers and partners are considered.

(2) Practitioner Claims Processing Requirements (FLG32)

     Develops and issues specifications, requirements, 
procedures, and instructional material to process claims from 
physicians and other independent medical professionals and defines 
their application to these physicians and other independent medical 
professionals (Certified Registered Nurse Anesthetists, clinical 
psychologist and clinical social workers) as well as Medicare 
contractors and beneficiaries.
     Develops and issues instructions for, as well as monitors, 
implementation of practitioner provider pricers.
     Develops applicable bill processing edits for contractor 
and Common Working File (CWF) processing of claims from physicians and 
other independent medical professionals. Coordinates with the Office of 
Analysis and Systems to implement these changes at contractors.
     Identifies vulnerabilities in Medicare claims processing 
requirements and implements instructions and guidelines for 
safeguarding program expenditures (administrative and benefit).
     Maintains the contractor/provider instructional manuals 
including CWF interface instructions for processing bills from 
physicians and other independent medical professionals contractor 
payment program for physicians and other independent medical 
professionals.
     Reviews proposed changes in Medicare policy, regulations, 
and law to evaluate the operational impact on practitioner claims 
processing operations including the development of cost estimates for 
the implementation of such proposals.
     Maintains liaison with representatives of the health care 
industry to ensure that HCFA processes are compatible with professional 
medical field administrative practices.
     Maintains liaison with beneficiaries, providers, 
contractors, and other partners for purposes of ensuring that 
continuous improvements are made to HCFA processes and that the 
interests of customers and partners are considered. 

[[Page 42894]]


(3) Supplier Claims Processing Requirements (FLG33)

     Develops and issues specifications, requirements, 
procedures, and instructional material to process claims from Medicare 
suppliers of services and defines their applications to these suppliers 
(durable medical equipment, ambulance, labs, orthotics and prosthetics, 
oxygen and parental and enteral nutrition), Medicare contractors, and 
beneficiaries.
     Develops and issues instructions for, as well as monitors, 
implementation of supplier provider pricers.
     Develops applicable processing edits for contractor and 
Common Working File (CWF) processing of claims from physicians and 
other independent medical professionals. Coordinates with the Office of 
Analysis and Systems to implement these changes at contractors.
     Identifies vulnerabilities in Medicare claims processing 
requirements and implements instructions and guidelines for 
safeguarding program expenditures (administrative and benefit).
     Maintains the contractor/provider instructional manuals 
including CWF interface instructions for processing bills from 
physicians and other independent medical professionals.
     Implements new legislation impacting on the contractor 
payment program for physicians and other independent medical 
professionals.
     Reviews proposed policy, reimbursement, and legislative 
proposals to evaluate the operational impact on supplier claims 
processing operations including the development of cost estimates for 
implementation of such proposals.
     Maintains liaison with representatives of the health care 
industry to ensure that HCFA processes are compatible with the 
professional medical field administrative practices.
     Maintains liaison with beneficiaries, providers, 
contractors, and other partners for purposes of ensuring that 
continuous improvements are made to HCFA processes and that the 
interests of customers and partners are considered.

(4) Standards Setting (FLG34)

     Develops and issues specifications, requirements, 
procedures, and instructional material related to electronic formats 
for claims, electronic funds transfer, remittance advice, eligibility, 
coordination of benefits, and any other claims processing items related 
to electronic transactions.
     Develops and maintains billing forms and formats used by 
contractors including the HCFA-1450 (UB-82) and the HCFA-1500.
     Develops, monitors, and approves all aspects of the notice 
of utilization.
     Develops programs to promote acceptance and usage of 
electronic claims processing, electronic funds transfer, and electronic 
remittance advice.
     Coordinates with stakeholders (providers, contractors, and 
HCFA components) to develop standardized data content for paper and 
electronic administrative transactions, such as claims, attachments, 
remittance advice, and eligibility inquiries.
     Serves as BPO focal point with the American National 
Standards Institute (ANSI) on electronic information formats used by 
the health insurance industry.
     Represents HCFA at the National Uniform Billing Committee 
and other established standards organizations to ascertain that HCFA's 
requirements are met.
     Reviews proposed changes in Medicare policy, regulations, 
and law to evaluate the operational impact on claims processing 
activities, including the development of cost estimates for the 
implementation of such proposals.
     Maintains liaison with beneficiaries, providers, 
contractors, and other partners for purposes of ensuring that 
continuous improvements are made to HCFA processes and that the 
interests of customers and partners are considered.
     Identifies vulnerabilities in Medicare claims processing 
requirements and implements instructions and guidelines for 
safeguarding program expenditures (administrative and benefit).

(5) Provider Enrollment (FLG35)

     Develops and issues specifications, requirements, 
procedures, and instructional material for provider enrollment and 
enumeration. Provides for the maintenance of the provider data base.
     Develops and issues general provider operating policy and 
procedures for the processing of Medicare claims that relate to any 
facet of provider applications and enumeration of provider applicants 
including standardizing the format(s), identifying data to be furnished 
by providers, and contractor validation/ verification of application 
data submitted by non-institutional providers.
     Develops applicable bill processing edits for contractor 
and Common Working File (CWF) processing of claims from Medicare 
providers.
     Develops budget guidelines and cost estimates for Medicare 
claims processing activities.
     Develops instructions and maintains the contractor and 
provider instructional manuals applicable to provider enrollment, 
enumeration, and requirements.
     Oversees the National Supplier Clearinghouse and the 
Uniform Provider Identification Number (UPIN) Registry activities which 
include monitoring carrier ongoing maintenance of UPIN Registry, 
managing the printing of UPIN Directory, and overseeing UPIN data 
cleanup to resolve issues involving missing/discrepant UPIN data.
     Works with the Bureau of Data Management and Strategy in 
developing and implementing the National Provider File and enumerating 
providers with the National Provider Identifier.
     Reviews proposed changes in Medicare policy, regulations, 
and law to evaluate the operational impact on provider qualification 
and enumeration including the development of cost estimates for the 
implementation of such proposals.
     Maintains liaison with representatives of the health care 
industry to ensure that HCFA processes are compatible with their 
administrative practices.
     Maintains liaison with providers, contractors, and other 
partners for purposes of ensuring that continuous improvements are made 
to HCFA processes and that the interests of customers and partners are 
considered.
     Identifies vulnerabilities in Medicare claims processing 
requirements and implements instructions and guidelines for 
safeguarding program expenditures (administrative and benefit).

(6) Benefit Coordination (FLG36)

     Develops, implements, and administers Medicare Secondary 
Payer (MSP) operational policy for coordinating Medicare benefits with 
other health insurance benefits. Analyzes and evaluates specific 
operating policy and procedural problems in the benefit coordination 
program and initiates proposals to better achieve program objectives as 
they relate to claims processing.
     Develops applicable bill processing edits for contractors 
and the Common Working File (CWF) for application of MSP claim 
processing policy and works with the Office of Analysis and Systems to 
implement these edits at contractor and CWF sites.
     Develops, implements, and administers Medigap operational 
policy 

[[Page 42895]]
(Section 1882 of the Social Security Act).
     Develops and implements a unique national payer 
identifier.
     Maintains the contractor and provider instructional 
manuals including CWF interface instructions for MSP claims processing 
policy.
     Implements new legislation impacting on the provider MSP 
payment process.
     Plans and directs operational liaison and outreach 
activities including public relations, publications, conferences, and 
presentations.
     Participates in the design, performance, and analysis of 
evaluations of contractor MSP pre-pay performance assessment.
     Analyzes State laws and regulations for Medicare 
supplemental health insurance to ensure compliance with Section 1882 of 
the Social Security Act. Prepares recommendations regarding approval or 
disapproval, or other appropriate actions, to the appropriate HCFA 
official.
     Develops national MSP budget and annual performance 
objectives for pre-pay activities. Analyzes contractors' MSP 
expenditures and goal performance.
     Reviews proposed changes in Medicare policy, regulations, 
and law to evaluate the operational impact on claims processing 
activities related to MSP and Medigap including the development of cost 
estimates for the implementation of such proposals.
     Maintains liaison with representatives of the health care 
industry to ensure that HCFA processes are compatible with provider 
administration practices.
     Maintains liaison with beneficiaries, providers, 
contractors, and other partners for purposes of ensuring that 
continuous improvements are made to HCFA processes and that the 
interests of customers and partners are considered.

e. Office of Contract Administration (FLG4)

     Administers contracts with private organizations to 
perform various aspects of Medicare program operations.
     Develops, negotiates, maintains, and modifies primary 
contracts and agreements with intermediaries, carriers, and other 
organizations authorized under Title XVIII of the Social Security Act.
     Provides direction and guidance to central office and 
regional office staff on Medicare intermediary and carrier contracts 
and procurement activities.
     Establishes policies and procedures to be used by Medicare 
intermediary and carrier contractors in the procurement of personnel, 
equipment, facilities management, software, and other services.
     Establishes financial management policies and procedures 
by which Medicare contractors prepare and submit periodic budget 
estimates.
     In consultation with other HCFA and bureau components, 
develops and negotiates the national budget for Medicare contractors.
     Controls and manages the Medicare cash flow and related 
banking activities. Monitors benefit payment expenditures.
     Reviews periodic contractor expenditure reports to 
evaluate Medicare budget execution and determines the allowability of 
costs. Prepares analysis of Medicare intermediary and carrier 
expenditure trends and patterns.
     Serves as bureau-wide support for participation in agency 
and department strategic planning and information resource management 
planning. Evaluates Medicare operational contracting arrangements, 
formulates recommendations for improvements, and develops appropriate 
implementation plans.
     Develops plans for possible transitions between new and 
current contractors and manages transition activities in coordination 
with the regional offices and HCFA components. Evaluates the impact of 
contractor transitions on HCFA's customers and strives for process 
improvements and responsiveness to customer needs.
     Plans, develops, and directs Medicare intermediary and 
carrier operating contracting experiments.
     Makes recommendations to agency management on proposed 
contract management actions for Medicare contractors determined to have 
serious performance deficiencies.
     Develops, implements, and monitors national performance 
evaluation programs to assess and improve overall effectiveness and 
quality of Medicare contractor operations.

(1) Acquisitions and Contracts (FLG41)

     Develops, maintains, negotiates, and modifies all 
agreements with intermediaries and contracts with carriers, as 
authorized under Title XVIII of the Social Security Act, and related 
contracts necessary to the Medicare program.
     Develops procedures for the award, non-renewal, 
termination, extension, and amendment of Medicare contracts.
     Represents the Contracting Officer in processing 
contractor claims resulting from changes in contract requirements and 
litigation activities related to contract disputes or protests 
involving selection or non-selection of contractors.
     Directs contract-related surveys requested by both the 
Executive and Legislative Branches of the Federal Government.
     Directs, coordinates, and serves as the HCFA resource in 
regard to technical contracting and procurement issues and maintains 
oversight on regional activity regarding Medicare contracting.
     Reviews contractors' requests for change orders and 
adjustments in price, determines where liquidated damages should be 
assessed against contractor, and takes appropriate action.
     Develops Medicare acquisition policy, providing technical 
acquisition guidance, and maintains Medicare contractor procurement 
procedures.
     Serves as bureau coordinator with the Office of Research 
and Demonstration on demonstration projects that impact Medicare 
contractor operations.
     Serves as the bureau focal point on the Small and 
Disadvantaged Business Subcontracting Program (SADBUS) requirements. 
Reviews and approves contractors' SADBUS plans and oversees related 
regional office monitoring.
     Provides liaison with contractor management.

(2) Financial Management (FLG42)

     Provides leadership in developing, implementing, and 
evaluating policies and procedures for the Medicare contractor budget 
formulation and execution process.
     Formulates and approves the national budget for Medicare 
contractor administrative costs.
     Develops, implements, and monitors cash management letter-
of-credit procedures for contractors and servicing banks.
     Develops, implements, and monitors fund control for the 
Medicare contractor administrative costs.
     Sets requirements and procedures for contractors and 
regional offices to prepare and submit periodic budget estimates and 
reports.
     Participates and/or monitors negotiations and approval of 
all budgets and budget adjustments. Reviews periodic contractor 
expenditure reports to evaluate budget execution and to determine the 
appropriateness of costs.
     Designs, maintains, and as necessary, prepares 
specifications to revise the Contractor Administrative Budget and 
Financial Management System.
     Analyzes contractor administrative cost data and trends. 

[[Page 42896]]

     Directs and prepares instructions to guide regional office 
performance to assure consistency implementation of financial policy.
     Develops procedures and monitors regional office actions 
related to the contractor administrative cost settlement process, 
interprets cost principles, and makes recommendations on final 
determinations of allowability of costs.
     Develops, implements, and monitors a process for reporting 
Medicare benefit payments.
     Develops and maintains policy, procedures, and systems for 
contractor reporting consistent with the Chief Financial Officer's Act.

(3) Transition Management (FLG43)

     Manages, monitors, and provides oversight of contractor 
transition activities including replacement of departing contractors 
and the resulting transfer of workload, major pre-Medicare Transaction 
System (MTS) electronic data processing (EDP) systems conversions, 
functional re-alignments, geographic workload carve-outs, and MTS 
operating site transitions, in coordination with the regional offices.
     Develops and implements contingency plans including 
replacement strategies for contractors at risk of leaving the Medicare 
program.
     Evaluates implementation proposals associated with 
contractor transitions, major pre-MTS EDP systems transitions, 
functional re-alignments, geographic workload carve-outs, and MTS 
operating site readiness testing and transitions.
     Provides technical expertise and support to HCFA central 
and regional office staffs regarding transition activities.
     Evaluates the impact of transitions on HCFA's customers 
and strives for continuous process improvements and responsiveness to 
customer needs.
     Incorporates current procurement and operating policy as 
well as lessons learned from prior transitions into the Transition 
Handbook.
     Conducts training for central and regional office staff on 
successful transition management and monitoring techniques and 
strategies.
(4) Contract Management (FLG44)

     Works in partnership with regional offices, central office 
components, and Medicare customers in identifying and arriving at 
proposed performance expectations of Medicare contractors.
     Develops, implements, and monitors national performance 
evaluation programs to assess and improve the overall effectiveness and 
quality of Medicare contractor operations.
     Develops, conducts, directs, and monitors HCFA operational 
component(s) participation in quality assurance reviews and studies of 
selected areas of contractor operations.
     Initiates, interprets, evaluates, and maintains data on 
each Medicare contractor in terms of compliance with performance 
requirements and expectations.
     Analyzes information and data on inaccurate or 
inconsistent Medicare contractor performance and reviews and approves 
corrective action planning and monitoring including, where applicable, 
recovery of any misspent Trust Fund dollars.
     In response to program needs, works in cooperation with 
other HCFA components to design, develop, and conduct special internal/
external reviews, studies, projects and/or surveys which have an impact 
on contractor performance evaluation (includes development and 
implementation of the Medicare Transaction System).
     Reviews program instructions and evaluates policy and 
operations to improve Medicare program operations and implement policy 
and legislative directives.
     Provides information and makes recommendations to HCFA 
management concerning proposed contract management actions for Medicare 
contractors determined to have serious performance deficiencies.
     Designs and develops oversight requirements for Medicare 
contractors to assess their internal controls for assuring effective 
safeguard of program expenditures in compliance with the Federal 
Managers' Fiscal Integrity Act.
     Advises contractors on weaknesses identified in their 
internal controls and provides guidance on corrective action.
     Develops proposals and conducts needed analysis for 
benchmarking strategies for the Medicare Transaction System.

(5) Planning (FLG45)

     Provides support to HCFA staff in identifying 
opportunities for the achievement of Medicare program improvements and 
efficiencies through innovation in infrastructure support; including 
contracting, technology, and information resources.
     Provides bureau-wide guidance and provides planning 
support for those program office initiatives that relate to strategic 
planning and information resource planning objectives.
     Evaluates Medicare operational contracting arrangements, 
including provision of information and technological support, 
formulates recommendations for improvements and develops appropriate 
implementation plans.
     Evaluates contractor configurations and recommends 
contracting arrangements to perform or support specific functions or to 
serve in specified geographic areas.
     Provides planning assistance to HCFA staff in developing 
operational and contracting experiments to achieve program improvements 
and efficiencies.

f. Office of Customer Communications (FLG5)

     Serves as the primary bureau focal point for various 
Agency-wide communication programs dealing with direct interaction with 
our customers, e.g. beneficiary provider groups, regional offices, 
carriers, and fiscal intermediaries.
     Serves as the primary focal point for the bureau on 
operational as well as administrative inquiries including telephone 
inquiries from Presidential staffs, congressional offices, other 
government agencies, private institutions, and individuals seeking 
information concerning the various regulations and policies related to 
the administration of the Medicare program.
     Plans, develops, and issues operating policy, 
specifications, procedural requirements, and other materials to 
implement, maintain, and oversee the appeals process for Medicare Part 
A and Part B claims. Issues instructions to regional offices as well as 
intermediaries and carriers.
     Plans, directs, and issues operational policy and 
procedures for the establishment and maintenance of premium billing and 
collection and Medicare entitlement activities.
     Develops standard language for use by Medicare contractors 
in communicating with beneficiaries and providers.
     Coordinates policy and procedures concerning Privacy Act 
and Freedom of Information Act issues.
     Coordinates the preparation of manuals and other policy 
issuances required to meet the instructional and informational needs of 
providers, contractors, State agencies, regional offices, Peer Review 
Organizations, the Social Security Administration, and other audiences 
directly involved in the administration of HCFA programs.
     Participates in Medicare Transaction System workgroups and 
reviews deliverables that impact on the Office of Customer 
Communications program functions. 

[[Page 42897]]

     Serves as bureau lead on special communications projects 
and serves as bureau focal point for agency-wide communications 
initiatives.
     Serves as bureau focal point on interaction with the 
Social Security Administration relative to Medicare program operational 
issues.

(1) Appeals (FLG51)

     Plans, develops, and issues operating policy, 
specifications, procedural requirements, and other materials to 
implement, maintain, or refine the appeals process for Part A and Part 
B claims. This includes instructions to the regional offices as well as 
intermediaries and carriers.
     Plans, conducts, and evaluates studies and implements 
changes to streamline and make more effective the appeals process.
     Develops, plans, implements, and oversees procedures and 
activities to reduce unnecessary appeals.
     Reviews proposed policy, reimbursement, and legislative 
proposals to evaluate the operational impact of such proposals on the 
appeals process for Part A and Part B claims.
     Evaluates and makes recommendations concerning the impact 
of claims processing policy and procedures on appeals. Evaluates impact 
of the appeals program on Medicare claims.
     Identifies management's information needs for data 
relating to Administrative Law Judge's (ALJ) decisions concerning both 
Part A and B claims and initiates appropriate actions for establishing 
or modifying the reporting and information systems to satisfy these 
needs (i.e., ALJ database, reversal reports, decision reports, etc.).
     Implements new legislation impacting on the appeals 
process.
     Maintains liaison with Part A and Part B contractors, HCFA 
components, and all other customers (including beneficiaries, 
institutional providers, physicians/suppliers, and advocacy groups) 
which use and implement the appeals process.
     Provides direction to regional offices and contractors 
(including Hearing Officers) on appeals procedures and in developing 
solutions to specific appeals issues as they arise during contractor 
processing of claims or appeals (or during Social Security 
Administration (SSA), Office of Hearing and Appeals processing of 
appeals).
     Participates in cross-functional efforts with claims 
processing and particularly with benefits integrity efforts for medical 
review, overpayments, and some aspects of fraud and abuse.
     Participates in the budgeting for and monitoring of the 
appeals process.
     Acts as HCFA's liaison with SSA's Office of Hearings and 
Appeals (ALJ level and Appeals Council level) to resolve issues 
affecting the Medicare appeals process.
     Maintains and evaluates data on the volume and qualitative 
aspects of the appeals process.
     Participates in the development of requirements, design, 
and implementation of appeals activities in the Medicare Transaction 
System environment.

(2) Entitlement & Premium Billing (FLG52)

     Plans, develops, and issues operational policy, 
specifications, requirements, procedures, and instructional material 
for the establishment and maintenance of three major systems: 
Enrollment Database (EDB) for Medicare Entitlement, Separate Operations 
for Billing, Entitlement, and Remittances (SOBER) for direct billed 
beneficiaries, and the SMI and HI Premium Accounting Collection and 
Enrollment System (SPACE) for third-party arrangements for States, the 
Office of Personnel Management (OPM), and formal groups.
     Plans, develops, issues operational policies, systems 
specifications, systems requirements, procedures and instructional 
material to administer the Medicare Lock-box premium collection 
operations for the direct billing operation and premium collections 
authorized by State Buy-In agreements, formal third-party group 
arrangements, and OPM.
     Develops contracts and negotiates agreements and 
modifications to efficiently administer the collection activities of 
the direct billing operations and production of the Carrier Alphabet 
State File and Beneficiary State File (CASF/BEST) for contractors, Peer 
Review Organizations, Railroad Retirement Board, and State agencies.
     Maintains liaison and works closely with the Social 
Security Administration (SSA) operational components, HCFA central and 
regional office components, State Agencies, the Railroad Retirement 
Board, and third-party groups on premium collection issues and 
beneficiary services related matters.
     Maintains liaison activities and works closely with SSA 
components, HCFA components, Medicare contractors, and the Railroad 
Retirement Board on entitlement issues.
     Resolves entitlement problems that cannot be done by the 
regional offices. Monitors the process and develops procedures for 
issuing and reissuing health insurance (HI) cards and monitors the 
Bureau of Data Management and Strategy (BDMS) records maintenance and 
correction.
     Oversees and reviews the processing of voluntary 
withdrawals, the identification of entitlement problems from the 
Medicare claim process and the Common Working File, and the process of 
providing direct input facilities with the date of death, name, and 
rejects from field offices. Develops SSA district office instructions 
on entitlement, HI cards, withdrawals, and premiums.
     Resolves premium billing and collection problems for 
States, OPM, the Railroad Retirement Board, third-party groups, and 
beneficiaries in direct billing status.
     Provides training and technical assistance to HCFA 
regional and central office personnel, State Agencies, and SSA 
personnel on enrollment, entitlement, HI cards, and premium billing and 
collection activities.
     Plans, conducts, and evaluates studies to improve systems 
methods and procedures pertaining to entitlement and premium 
collections.
     Develops, analyses, and recommends legislative and policy 
proposals pertaining to entitlement and premium collection issues.
     Validates BDMS initiated systems changes in entitlement.

(3) Issuances (FLG53)

     Plans, directs, develops and coordinates the preparation 
of manuals and other instructional materials to meet the instructional 
and informational needs of contractors, providers, State agencies, 
regional offices, Peer Review Organizations, the Social Security 
Administration, and other audiences directly involved in the 
administration of the Medicare and Medicaid programs.
     Prepares and coordinates preparation of written documents 
that assists the Director, Bureau of Program Operations, in resolving 
program and administrative policy issues.
     Manages the HCFA-wide system for developing instructions, 
setting instructions priorities, and coordinating work schedules 
related to instructions.
     Maintains an ongoing review system, including clearance of 
instructions, to ensure clarity and consistency. Identifies 
instructional needs and initiates development of instructions by HCFA 
components.
     Reviews instructional materials prepared by regional 
offices, contractors, and others that impact on HCFA instructions for 
conformance with national policies and procedures. 

[[Page 42898]]

     Represents HCFA on issues involving instructions issued by 
the Social Security Administration and the Office of the Inspector 
General dealing with the Medicare and Medicaid programs.
     Initiates and develops plans for changes to the manual 
issuances system as it is impacted by the Medicare Transaction System.
     Prepares the quarterly Federal Register notice of 
instructional and informational materials issued by HCFA.
     Manages the manual issuances database (Text Information 
Management System) and the preparation of manual issuance database 
material for production of CD-ROM.

(4) Medicare Customer Assistance (FLG54)

     Develops and coordinates responses to all inquiries, both 
written and telephone, directed to the Bureau of Program Operations on 
the operational aspects of the Medicare Program received from a wide 
range of customers including beneficiaries, providers, Congressional 
Staffs, public interest groups, White House Staff, etc.
     Conducts analyses and studies to identify trends in 
customer needs and alerts appropriate bureau staff. Works in 
partnership with bureau staff to identify and resolve areas of customer 
concern with the Medicare program.
     Directs the management of the bureau's assignment control 
system including the receipt, review, coordination, and control of all 
correspondence and assignments. Prepares or coordinates the preparation 
of responsive replies for signature of the Secretary of the Department 
of Health and Human Services, the Administrator of HCFA, the Director 
of the Bureau of Program Operations, and other high level management 
officials.
     Establishes and maintains contact with HCFA's Executive 
Secretariat, the Office of Legislative and Inter-Governmental Affairs, 
the Freedom of Information and Privacy Office, the Office of the 
General Counsel, and other HCFA components and federal departments and 
agencies, to coordinate correspondence replies.
     Coordinates policy and procedures concerning Privacy Act 
and Freedom of Information Act issues for the bureau.
     Provides guidance and technical assistance to bureau and 
HCFA regional office staff on procedures and standards for content of 
memoranda and correspondence.
     Provides management reports to senior bureau staff on the 
quality and timeliness of the customer assistance and assignment 
coordination processes.

(5) Communications (FLG55)

     Develops, monitors, and approves formats and messages for 
the Explanation of Medicare Benefits.
     Initiates improvements and develops procedures for 
providing beneficiary and provider services for telephone, written, and 
personal contacts by Medicare contractors and other field facilities.
     Develops standard language for use by Medicare contractors 
in communicating with beneficiaries and providers.
     Plans, conducts, and evaluates studies and pilots to 
develop both long-range and short-range improvements in system 
requirements, methods, and procedures relating to beneficiary and 
provider communications.
     Approves funding requests and monitors contractor project 
plans for beneficiary and provider outreach activities.
     Works in direct partnership with HCFA customers in order 
to improve the communications process between HCFA and its customers.
     Validates and analyzes data relating to beneficiary and 
provider communications (e.g., telephone usage, pilot trends and 
findings) and prepares statistical reports for distribution to HCFA 
Senior Staff, BPO components, and the regional offices.

g. Medicare Transaction System Initiative Task Force (FLG6)

     Serves as the Agency focal point for the management and 
coordination of the Medicare Transaction System initiative (MTSI). 
Represents HCFA to the Department, other Federal Agencies, and outside 
organizations.
     Provides direction and technical guidance for the design, 
development, implementation, verification and validation, and 
maintenance of the Medicare Transaction System (MTS) to integrate 
Medicare Part A and Part B claims processing systems.
     Provides technical management, oversight, coordination, 
and day-to-day monitoring of contract(s) for the MTS design and the 
independent verification and validation of the MTS design, development, 
validation, implementation, and maintenance activities.
     Recommends alternatives to existing requirements, 
operational priorities, processes, procedures, and methods for 
improvement which will enhance the quality and cost-effectiveness of 
Medicare operational and administrative procedures and meet the needs 
of HCFA's internal and external customers.
     Develops, implements, and directs project planning, 
control, and administrative procedures, processes, and methods used to 
determine MTSI program status, assess performance, report progress, and 
implement changes.
     Develops, implements, directs, and operates activities to 
assure the quality of the MTSI development throughout the system 
development life cycle.
     Provides direction and technical guidance for the 
transition of Medicare claims processing from the current Part A and 
Part B systems to the integrated MTS, operating sites, and local 
contractor operations.
     Oversees the development of specifications for, and 
management of, any procurements that are necessary to conduct 
experiments incorporating approved alternatives to existing processes 
and procedures.
     Coordinates with HCFA components in the planning, 
development, and implementation of projects which impact on or are 
impacted by the MTSI.

(1) Medicare Transaction System Quality Assurance (FLG61)

     Develops, implements, directs, and operates activities to 
assure the quality of Medicare Transaction System (MTS) development 
throughout the system development life cycle.
     Provides technical management, oversight, coordination and 
day-to-day monitoring of contract(s) for the independent verification 
and validation of MTS analysis, design, development, validation, 
implementation, and maintenance activities.
     Reviews and evaluates the effectiveness of the processes 
and procedures used to analyze, design, develop, implement, and 
maintain the MTS.
     Provides the documentation and analysis necessary to 
initiate and support corrective action resulting from findings of the 
MTS quality assurance activities.
     Reviews and evaluates quality assurance programs 
maintained by the MTS design contractor, the independent verification 
and validation contractor and HCFA to ensure integration of quality 
assurance activities throughout the MTS development process.
     Recommends alternatives to proposed methodologies for the 
analysis, design, development, validation, implementation and 
maintenance of the MTS. 

[[Page 42899]]


(2) Medicare Transaction System Development (FLG62)

     Develops, implements, and directs activities to assure the 
development of the Medicare Transaction System (MTS) throughout the 
system development life cycle.
     Provides technical management, oversight and coordination 
and day-to-day monitoring of the contract(s) for performing the 
Medicare Transaction System (MTS) analysis, design, development, 
validation, implementation, and maintenance activities.
     Provides the inter- and intra-component coordination 
required to insure appropriate and timely review and dissemination of 
the contract work products and other pertinent information.
     Reviews and evaluates the effectiveness of the processes 
and procedures used to coordinate and facilitate the review of the 
contract work products.
     Develops, conducts, and coordinates modifications to 
existing operational procedures, contracts, reporting mechanisms and 
related materials as required.
     Provides the documentation and analysis necessary to 
initiate and support corrective action resulting from the findings of 
the MTS development activities.

(3) Medicare Transaction System Program Planning & Needs Analysis 
(FLG63)

     Recommends alternatives to existing requirements, 
operational priorities, processes, procedures, and methods for 
improvement which will enhance the quality and cost-effectiveness of 
Medicare operational and administrative procedures and meet the needs 
of HCFA's internal and external customers.
     Develops, implements, and directs project planning, 
control and administration procedures, processes, and methods used to 
determine Medicare Transaction System initiative (MTSI) program status, 
assess performance, report progress, and implement changes.
     Maintains the MTSI program schedule and MTSI program 
management plan and various program management databases.
     Provides advisory and consultative services on project 
planning to HCFA central and regional office staff and key officials 
responsible for planning and implementing projects in support of the 
development and implementation of the Medicare Transaction System.
     Conducts project planning training to HCFA staff 
responsible for MTSI projects.

    Dated: July 31, 1995.
Bruce C. Vladeck,
Administrator, Health Care Financing Administration.
[FR Doc. 95-20317 Filed 8-16-95; 8:45 am]
BILLING CODE 4120-01-P