ClaimsCore Combined Synopsis/Solicitation

Solicitation / RFP / RFQ

This document provides "Instructions to Offerors" for Solicitation # 75FCMC26R0022, related to ClaimsCore. It outlines the requirements and procedures for submitting proposals. The procurement is subject to future availability of funds.

• Proposals must be viewable in Microsoft Office or Adobe Acrobat.

• Submissions must be letter-sized (8-1/2 X 11") with one-inch margins, single-spaced.

• Font size should be 12-point, with a minimum of 9-point for tables, graphics, etc.

• Tables should be formatted for searchability, avoiding images.

• Electronic mail submissions should be kept below 25MB.

• If a Contractor Teaming Agreement (CTA) is proposed, it must be indicated, and all team members identified.

• Subcontracting plans, if required, must be submitted with Phase 2 proposals.

• The solicitation does not commit the Government to pay for proposal preparation or submission costs.

• The Government estimates up to four (4) awards will be made.

• Written Questions: Due no later than 11:00 am ET on 03/06/2026, submitted via email. Questions and CMS responses may be shared.

• Phase One Proposal Due Date: 03/13/2026, at 11:00 a.m. ET, submitted via email to Lauren Holsey (Lauren.Holsey@cms.hhs.gov) and cc: Candace Straker (Candace.Straker@cms.hhs.gov). Offerors must cite their Unique Entity ID (UEI) and SAM EIN.

• Phase Two Proposal Documentation: To be provided via email to Lauren Holsey and cc: Candace Straker.

• Evaluation: Proposals will be evaluated using a tradeoff process to determine Best Value. Non-price factors (Corporate Experience, PWS & QASP, Past Performance) are combined and are significantly more important than cost or price.

• Two-Phase Evaluation: Proposals will be submitted and evaluated in phases to minimize costs. An advisory down-select will occur between phases.

• Phase 1 Evaluation Factor: Corporate Experience (Mission Focused).

• Phase 2 Evaluation Factors: PWS & QASP, Past Performance, Price, Section 508, Business Ethics, Conflicts of Interest (COI), and Compliance.

• Not explicitly stated in this document, but references FAR 19.704 and FAR Clause 52.219-9 regarding subcontracting plans.

• Offerors should submit their best terms in their initial proposal as the Government may award without discussions.

• Specific instructions are provided for preparing the Corporate Experience, PWS & QASP, Past Performance, Price, Section 508, and COI volumes.

Amendment / Modification

This document, "Amendment 3 - Attachment 3 ClaimsCore Instructions to Offerors RL.docx," serves as an amendment to the original solicitation. It provides detailed instructions for offerors responding to the opportunity.

• Submission Format: Digital submissions should be letter-sized (8-1/2 X 11”), single-spaced, with one-inch margins. Page limitations apply and excess pages will not be considered. Front matter (cover letter, TOC, definitions) is excluded from page limits. Font size should be 12-point, with tables/graphics allowing 9-point. Tables should be text-searchable, not images.

• Electronic Mail Size: Keep attachments below 25MB.

• Contractor Teaming Agreements (CTAs): Proposals must identify CTA arrangements and team members. The prime offeror will be the contractor of record, responsible for payments.

• Subcontracting Plan: Required with Phase 2 proposals per FAR 19.704 and FAR Clause 52.219-9.

• Written Questions: Due by 11:00 am ET on 03/06/2026 via email. Questions received after this may not be answered. A specific format is required for questions, referencing RFP sections. CMS may not answer all questions or may hold Q&A sessions. Solicitation terms control over Q&A responses.

• Phase 2 Questions: Due by 11:00 am ET on the third business day following distribution of the Contracting Officer's notification.

• Proposal Submission: Phase One and Phase Two proposals are due via email by 11:00 a.m. ET on 03/13/2026 to Lauren Holsey (Lauren.Holsey@cms.hhs.gov) and cc Candace Straker (Candace.Straker@cms.hhs.gov). Include Unique Entity ID (UEI) and SAM EIN. Late submissions will not be considered.

• Evaluation: Proposals will be evaluated using a tradeoff process for Best Value. Non-price factors (Corporate Experience, PWS/QASP, Past Performance) are significantly more important than cost or price.

• Awards: Up to four awards are estimated.

• Two-Phase Evaluation: Proposals are submitted and evaluated in two phases. CMS will provide an advisory down-select notification between phases. Offerors not recommended for Phase 2 can opt-in.

  • Phase 1: Evaluates Corporate Experience (Mission Focused). Requires a 6-page narrative demonstrating recent, relevant performance in specific focus areas (claims processing, migrations, professional services, financial stability, provider burden, edit/rule conversion, payment integrity).
  • Phase 2: Evaluates PWS & QASP, Past Performance, and Price. Also evaluates Section 508, Business Ethics, Conflicts of Interest (COI), and Compliance.

• PWS/QASP: PWS must detail the proposed solution, tasks, deliverables, staffing, and assumptions (max 20 pages). Draft QASP (max 5 pages) must illustrate performance measurement. Inaccurate assumptions or unexplained exceptions may lead to unfavorably evaluation.

• Past Performance: Requires disclosure of CMS contracts/task orders > simplified acquisition threshold and relevant contracts with other government/commercial entities within the last 3 years. PPQs may be submitted for offerors without federal past performance.

• Price: Includes a narrative (cover letter, Basis of Estimate) and a spreadsheet. BOE should detail estimating methodology, labor, materials, and ODCs. Commercial price support is required. Subcontractor pricing details are needed. Certified cost or pricing data is not required, but fair and reasonable pricing must be demonstrated.

• Section 508: Offerors must submit an Accessibility Conformance Report (ACR) based on VPAT. This is evaluated for compliance for the apparent successful offeror only.

• COI: A "Contractor/Offeror Conflict of Interest" form must be submitted. Subcontractor COI analyses must be included. This is evaluated for the apparent successful offeror only.

• This amendment details the submission requirements, evaluation criteria, and phased approach for the solicitation.

Amendment / Modification

This amendment (Amendment 3) to Solicitation 75FCMC26R0022 serves to request offerors provide a copy of the "CTA, as applicable in Phase 2" as stated in "Amendment 3 - Attachment 3, ClaimsCore Instructions to Offerors."

• Attachments Added:

  • Attachment 12: "Amendment 3 - Attachment 3 Claims Core Instructions to Offerors" (Dated: 11 MAR 2026)

• Clauses Removed:

  • Clause 52.217-5 RFO "Evaluation of Options" (Effective Date: RFO DEVIATION NOV 2025)

Offerors are required to acknowledge receipt of this amendment. The specific impact on proposal submission deadlines or requirements is not detailed in this amendment, but offerors should ensure they provide the requested "CTA" as per the new attachment.

Amendment / Modification

This amendment (0002) to Solicitation 75FCMC26R0022 serves to correct the Phase 1 RFP submission due date as previously stated in Amendment 2 - Attachment 3, ClaimsCore Instructions to Offerors.

• Attachments: Amendment 2 - Attachment 3 ClaimsCore Instructions to Offerors was added with a reference number and date of 10 MAR 2026.
• Clauses: Clause 52.217-5, "Evaluation of Options," was removed, with an effective date of RFO DEVIATION NOV 2025.

This amendment modifies the submission due date for the Phase 1 RFP, as detailed in the updated ClaimsCore Instructions to Offerors attachment. Offerors should acknowledge receipt of this amendment and ensure their submissions align with the corrected due date.

Solicitation / RFP / RFQ

This document provides instructions to offerors for Solicitation # 75FCMC26R0022, "ClaimsCore Instructions." It outlines the requirements for preparing and submitting proposals, emphasizing that the solicitation does not commit the Government to any contract or payment.

• Format: Responses should be in Microsoft Office or Adobe Acrobat format, using letter-sized pages (8-1/2 X 11"), single-spaced, with one-inch margins. Landscape layout is acceptable for certain pages. Pages must be numbered consecutively.

• Font Size: Generally 12-point font, with a minimum of 9-point font acceptable for tables, graphics, headers, and footers. Avoid excessive use of charts.

• Tables: Tables must be formatted for text searchability in MS Office and Adobe Acrobat; avoid embedding tables as images.

• Electronic Submissions: Keep email attachments below 25MB.

• Contractor Teaming Agreements (CTAs): If proposed, CTAs must be clearly indicated, and team members identified. The prime contractor must be clearly identified for FPDS-NG records and payment.

• Subcontracting Plan: Required if applicable, to be submitted with Phase 2 proposals per FAR 19.704 and FAR Clause 52.219-9.

• Written Questions: Due by 11:00 am ET on 03/06/2026, submitted via email. Questions received after this date may not be answered.

• Proposal Submission: A two-phase process.

  • Phase One: Submission due by 03/13/2026, 11:00 am ET, via email to Lauren Holsey. Focuses on Corporate Experience (Mission Focused).
  • Phase Two: Documentation to be provided via email to Lauren Holsey. Focuses on PWS & QASP, Past Performance, Price, Section 508, Business Ethics, Conflicts of Interest (COI), and Compliance.

• Evaluation: Proposals will be evaluated using a tradeoff process to determine Best Value. Non-price factors (Corporate Experience, PWS & QASP, Past Performance) combined are significantly more important than cost or price. Up to four awards are estimated. The Government may award without discussions.

• Not explicitly detailed in this document, but subcontracting plans are mentioned.

• The document details specific requirements for each proposal volume, including Corporate Experience (6-page limit), PWS (20-page limit, excluding QASP), QASP (5-page limit), Past Performance, Price (including Cover Letter and Basis of Estimate), Section 508 compliance, and Business Ethics/COI.

• Offerors are responsible for ensuring their proposals meet all stated requirements and deadlines.

Amendment / Modification

This document, "Amendment 2 - Attachment 3 ClaimsCore Instructions to Offerors RL.docx," serves as an amendment to the original solicitation. It provides detailed instructions for offerors responding to the opportunity.

Key instructions include:

• Submission Format: Responses should be viewable in Microsoft Office or Adobe Acrobat, formatted for letter-sized pages (8-1/2 x 11"), single-spaced, with 1-inch margins. Digital submissions should be print-formatted.
• Page Limitations: Specific page limits may apply to response elements; excess pages will not be considered. "Front matter" (cover letter, TOC, definitions) is excluded from page limits.
• Font Size: Use 12-point font, with a minimum of 9-point font acceptable for tables, graphics, etc.
• Table Formatting: Tables should be formatted for text searchability, avoiding images of tables.
• Email Attachments: Keep email attachment sizes below 25MB.
• Contractor Teaming Agreements (CTAs): If proposing a CTA, clearly identify team members. The prime offeror must be the identified contractor, and CMS will only pay the prime.
• Subcontracting Plan: If required, submit with Phase 2 proposals per FAR 19.704 and FAR Clause 52.219-9.
• Written Questions: Submit questions via email by 11:00 am ET on 03/06/2026, referencing specific RFP sections. Questions received after this deadline may not be answered.
• Proposal Submission: Phase One proposals are due by 11:00 am ET on 03/01/2026, submitted via email to Lauren Holsey (Lauren.Holsey@cms.hhs.gov) and cc: Candace Straker (Candace.Straker@cms.hhs.gov). Include Unique Entity ID (UEI) and SAM EIN.

This amendment details submission requirements, question submission procedures, and proposal formatting for offerors.

Key deadlines for questions (03/06/2026) and Phase One proposals (03/01/2026) are specified. Offerors must adhere to strict formatting and submission guidelines to ensure their proposals are considered.

Statement of Objectives (SOO)

This Statement of Objectives (SOO) outlines the Centers for Medicare & Medicaid Services' (CMS) plan to re-platform its legacy "Shared Systems" for Medicare Fee-for-Service claims processing. The "ClaimsCore" program aims to replace systems like MCS, FISS, DME, and CWF with a flexible, interoperable Software as a Service (SaaS) platform. The primary objective is to improve administrative efficiency, enhance beneficiary experience, and enable greater policy agility.

• System Replacement: Replace outdated systems with a near real-time platform while ensuring uninterrupted Medicare operations.
• Beneficiary Transparency: Provide faster claims status, improved visibility into responsibility, and quicker explanations of benefits.
• Provider Burden Reduction: Increase transparency, consistency, and automation to improve revenue certainty for providers.
• Payment Integrity: Enhance fraud, waste, and abuse detection and prevention through real-time risk scoring and pre-payment edits.
• Policy Agility: Enable faster implementation and testing of new payment models and policies.
• Operational Efficiency: Improve data access, reporting, and analytics for better decision-making.
• Modernization: Retire legacy COBOL mainframe systems, reduce obsolescence risk, and improve system scalability and availability.

The ClaimsCore program will focus on replacing the core claims processing systems. It will involve integrating with existing MAC tools and systems rather than replacing them, except in exceptional circumstances. The scope includes supporting the end-to-end claim lifecycle, from intake and eligibility checks to payment determination, remittance, reporting, and audits.

The procurement will utilize a challenge-based acquisition process with multiple phases, including a Proof of Concept (POC) to assess vendor solutions against defined metrics before potential production implementation. CMS is seeking a SaaS-based COTS platform with associated configuration and integration services.

• System Performance: Near real-time adjudication, 99.9% uptime, horizontal scalability.
• Architecture & Standards: Alignment with CMS enterprise architecture and standards.
• SaaS Deployment: Options for fully managed SaaS or vendor-managed SaaS within CMS infrastructure.
• Security & Privacy: Compliance with FISMA Moderate, FedRAMP requirements, and all applicable HHS/CMS security and privacy policies.
• Interoperability: Support for HIPAA X12 and comprehensive APIs (REST/FHIR).
• Data Rights: CMS retains ownership and unlimited rights in all CMS data handled or produced.

The procurement process includes RFP acquisition, a Proof of Concept phase (ending Nov 4, 2026), Production Implementation, and a potential follow-on contract.

Solicitation / RFP / RFQ

This document provides "Instructions to Offerors" for Solicitation # 75FCMC26R0022, related to "ClaimsCore Instructions." It outlines the terms and conditions for submitting proposals and does not commit the Government to any payment for preparation or submission, nor does it guarantee a future contract. Procurement is subject to future availability of funds.

• Format: Responses should be viewable in Microsoft Office or Adobe Acrobat, formatted for letter-sized pages (8-1/2 x 11"), single-spaced, with 1-inch margins. Landscape layout is acceptable for certain pages. Pages must be numbered consecutively. "Front matter" (e.g., cover letter, table of contents) does not count towards page limitations. Font size should be 12-point, with 9-point acceptable for tables, graphics, headers, and footers. Tables should be text-searchable, not images.

• Electronic Submissions: For email submissions, keep attachment size below 25MB.

• Contractor Teaming Agreements (CTAs): If proposed, CTAs must be identified, and proposals must be consistent regarding CTA arrangements. The prime contractor will be identified in the FPDS-NG record, and payment will be made only to the prime contractor.

• Subcontracting Plan: If required, submit with Phase 2 proposals per FAR 19.704 and FAR Clause 52.219-9.

• Written Questions: Submit via email no later than 11:00 am ET on 03/06/2026. Questions received after this date may not be answered. A specific format for questions is provided.

• Proposal Submission:

  • Phase One: Submit via email to Lauren Holsey (Lauren.Holsey@cms.hhs.gov) and cc Candace Straker (Candace.Straker@cms.hhs.gov) by 03/01/2026, 11:00 am ET. Include Unique Entity ID (UEI) and SAM EIN.
  • Phase Two: Submit via email to Lauren Holsey.

• Late Submissions: Late responses will not be considered. The entire response will be considered late if any portion is late.

• Evaluation: Proposals will be evaluated using a tradeoff process to determine Best Value. Non-price factors (Corporate Experience, PWS & QASP, Past Performance) are combined and are significantly more important than cost or price. Conflict of Interest (COI) and 508 VPAT submissions will be evaluated for compliance but not for best value.

• Two-Phase Procurement: Proposals are evaluated in phases to minimize costs and evaluation time. An advisory down-select will occur between phases.

• Not explicitly detailed in this document, but subcontracting plans are mentioned.

• The Government may award without discussions. Offerors should submit their best terms initially.

• The PWS must not exceed 20 pages (excluding QASP), and the QASP must not exceed 5 pages.

• Section 508 accessibility standards and requirements for Accessibility Conformance Reports (ACR) and Voluntary Product Accessibility Templates (VPAT) are detailed.

• Business Ethics, Conflicts of Interest (COI), and Compliance must be addressed.

Amendment / Modification

This amendment (0001) to Solicitation 75FCMC26R0022 serves multiple purposes:

• Provides responses to RFP questions.

• Issues an Amended Solicitation.

• Provides an amended Attachment 1 - ClaimsCore SOO.

• Provides an amended Attachment 3 - ClaimsCore Instructions to Offerors.

• Renames and provides an amended Attachment 6 - Beneficiary Quantities Claims and Unit Pricing.

• Special Contract Requirements: The "True Up Clause" has been modified. This clause details the annual prospective adjustment of firm fixed prices for CLINs 0004, 0006, 0008, 0010, 0012, and 0014 based on changes in beneficiary quantities or claim volumes. It outlines the reporting requirements for the contractor (90 days prior to the end of the current performance period) and the process for the Contracting Officer to unilaterally adjust prices for the subsequent option period. CLIN 0002 is excluded from this adjustment.

• Attachments: The following attachments have been added or amended:

  • Amendment 1 - Attachment 1 ClaimsCore SOO
  • Amendment 1 - Attachment 3 ClaimsCore Instructions to Offerors
  • Amendment 1 - Attachment 6 Beneficiary Quantities Claims and Unit Pricing
  • ClaimsCore Consolidated Q&A

• The amendment provides an amended solicitation and related attachments, which may impact proposal preparation.

• The "True Up Clause" modification affects how pricing for specific CLINs will be adjusted in future option periods.

• The clause 52.217-5 RFO, "Evaluation of Options," has been removed.

• The clause 52.204-15 RFO, "Service Contract Reporting Requirements for Indefinite-Delivery Contracts," is noted.

Questions & Answers / Clarifications

This document contains questions submitted by potential offerors and the government's responses regarding the ClaimsCore solicitation.

• Proof of Concept (PoC) Data & Scope: The PoC will use historical production data, not de-identified sets. Approximately 100 million claims are expected for the test data set, covering Parts A, B, and DME. Synchronization between the new solution and legacy systems is not required during the PoC, only in production.
• Integration & Data: Offerors should expect to receive most data from S3 buckets as flat files. APIs are generally not expected for the PoC. Integration with Tier 1 systems is required, with specific details to be provided at onboarding. Data quality for historical data is believed to exist in accessible formats, but access to VSAM files can be provided if needed.
• Timeline & Deadlines: The PoC is scheduled from May 5, 2026, to November 4, 2026. Phase 2 proposals will be due two weeks after the Phase 1 down-select notification.
• Contract Type & Pricing: The government has determined that a Firm-Fixed-Price (FFP) contract type remains appropriate and will not change services CLINS to Time & Materials (T&M). Pricing may be based on a Per Member Per Month (PMPM) basis or claim volume, with flexibility for offerors.
• Small Business Subcontracting Plan: Submission of a Small Business Subcontracting Plan will be required with the Phase 2 proposal.
• Security: A full Authority to Operate (ATO) is not required for the PoC; vendors must demonstrate an ATO-ready security posture. Production deployment will require full CMS security and compliance.
• Business Logic: While CMS will provide extracted business logic, offerors are ultimately responsible for its discovery and implementation to achieve parity with legacy systems. The legal source of truth is published policy, regulation, and guidance.

Several clauses were removed or amended based on vendor questions, including the removal of FAR 52.204-15 and updates to instructions regarding subcontractor pricing and small business subcontracting plans. The solicitation has been updated to clarify requirements and address ambiguities.

Amendment / Modification

This document, "Amendment 1 - Attachment 3 ClaimsCore Instructions to Offerors RL.docx", appears to be an attachment related to a solicitation, specifically providing "Instructions to Offerors". It details the requirements for proposal preparation and submission, including formatting, page limitations, font size, and electronic submission guidelines. It also outlines the submission process for written questions, including deadlines and formatting. The amendment specifies the two-phase evaluation process, detailing the factors for Phase 1 (Corporate Experience) and Phase 2 (PWS & QASP, Past Performance, Price, Section 508, Business Ethics, COI, and Compliance). It provides detailed instructions on how to prepare and what to include in each proposal volume, including specific requirements for Corporate Experience, PWS/QASP, Past Performance, Price, Section 508 compliance (VPAT/ACR), and Business Ethics/COI. It also specifies submission deadlines for questions and proposals.

• Instructions for proposal preparation and submission (formatting, page limits, font size).

• Process for submitting written questions.

• Two-phase evaluation process and criteria for each phase.

• Requirements for Corporate Experience, PWS/QASP, Past Performance, Price, Section 508, and COI volumes.

• Clarifies proposal submission requirements and evaluation factors.

• Sets deadlines for questions (03/06/2026) and proposal submission (03/01/2026 for Phase One).

Form / Attachment / Pricing Sheet

This attachment (Attachment 6) establishes the estimated beneficiary quantities and fixed unit prices for calculating firm-fixed prices for specific CLINs (Contract Line Item Numbers) that are subject to an annual prospective price adjustment, referred to as the "True-Up." Offerors can propose pricing using either Beneficiary-Based (Per Member/Per Month - PMPM) Pricing or Claims Volume-Based (Per Claim) Pricing.

• Applicable CLINs: CLINs 0004, 0006, 0008, 0010, 0012, and 0014 are subject to adjustment. CLINs 0002 is excluded.
• Unit Pricing Assumptions: Prices are firm-fixed monthly PMPM for software services as defined in the PWS. Beneficiary and claims counts are based on unique monthly counts processed through the contractor's system.
• Pricing Methodologies:
  • Beneficiary-Based (PMPM): Calculated Annual CLIN Price = Estimated Average Monthly Beneficiaries × Unit Price × 12 Months.
  • Claims Volume-Based (Per Claim): Annual CLIN Price = Estimated Average Monthly Claims Volume × Unit Price per Claim × 12 Months.
• Estimated Quantities and Prices: Tables provide estimated average monthly beneficiaries and claims volumes for specific performance periods (e.g., 11/05/2027 – 11/04/2028 for CLIN 0004). Unit prices (TBD) and calculated annual prices are to be determined.
• Annual True-Up Submission: Contractors must submit an updated version of this attachment in MS Excel format within 90 days before the current performance period ends. This submission should include actual beneficiary counts, revised projected quantities, and recalculated prospective CLIN prices, supported by a basis of estimate and historical trends.

This document is critical for bidders as it outlines the pricing structure and assumptions for a significant portion of the contract. It details how prices for specific CLINs will be calculated and adjusted annually. Bidders must understand these pricing methodologies (PMPM or Per Claim) and the estimated volumes to formulate their proposals accurately. The "TBD" values for unit prices indicate areas where offerors will need to provide their pricing, and the submission requirements for the annual True-Up process are also key considerations for ongoing contract management.

Form / Attachment / Pricing Sheet

This attachment establishes the estimated beneficiary quantities, estimated claims volume, and fixed unit prices for CLINs subject to an annual prospective price adjustment ("True-Up"). It provides the basis for calculating firm-fixed prices for these CLINs.

• Pricing Methodologies: Offerors can propose pricing based on either Beneficiary-Based (Per Member Per Month - PMPM) or Claims Volume-Based (Per Claim).
• Applicable CLINs: The quantities and prices apply to CLINs 0004, 0006, 0008, 0010, 0012, and 0014. CLIN 0002 is excluded.
• Unit Pricing Assumptions: Unit prices are firm-fixed monthly prices per unique beneficiary (PMPM) or per claim processed, applied to software services as defined in the PWS. Counts are based on monthly processed beneficiaries and claims.
• Estimated Quantities and Prices: Tables provide estimated average monthly beneficiaries and unit prices (PMPM) and estimated monthly claims volume and unit prices (Per Claim) for various performance periods. For CLIN 0004, the estimated monthly beneficiaries are 33,564,990 and the estimated monthly claims volume is 95.3M. Unit prices and calculated annual prices for CLIN 0004 are TBD, and for other CLINs are listed as XXXX.
• True-Up Submission Requirements: The Contractor must submit an updated version of this attachment in MS Excel format annually, no later than 90 days before the end of the performance period. This submission should include actual beneficiary/claim counts for the current period and revised projections for future periods, along with supporting documentation.

This document is crucial for bidders to understand the basis of pricing for the Medicare Claims Processing Software. It outlines the expected volumes and the pricing structure (PMPM or Per Claim) that will be used for calculating contract costs. Bidders need to use this information to develop their proposals and understand how future price adjustments will be calculated based on actual volumes. The TBD and XXXX values indicate areas where specific pricing needs to be proposed or will be determined.

Solicitation / RFP / RFQ

This document provides instructions to offerors for Solicitation #75FCMC26R0022, related to "Claims Core". It outlines the requirements for preparing and submitting proposals.

• Proposals must be in a format viewable by Microsoft Office or Adobe Acrobat.

• Digital submissions must be letter-sized (8-1/2 x 11"), single-spaced, with one-inch margins. Landscape layout is acceptable for certain pages.

• Responses should use a 12-point font size, with a minimum of nine-point font for tables, graphics, etc.

• Tables should be formatted for text searchability, avoiding images of tables.

• Electronic mail attachments should be kept below 25MB.

• Contractor Teaming Agreements (CTAs) must be clearly indicated, with the prime contractor identified as the entity receiving payment.

• The procurement is subject to future availability of funds.

• The Government estimates up to four (4) awards will be made.

• Written questions are due by 11:00 am ET on 03/06/2026. Questions should be submitted via email and reference specific RFP sections.

• Phase One proposals are due by 03/13/2026, 11:00 am ET, submitted via email to Lauren Holsey.

• Phase Two proposal documentation is also submitted via email to Lauren Holsey.

• Proposals will be evaluated using a tradeoff process to determine Best Value.

• Evaluation factors (in descending order of importance) include: Corporate Experience (Mission Focused), Performance Work Statement (PWS) & Quality Assurance Surveillance Plan (QASP), and Past Performance. Conflict of Interest (COI) and Section 508 VPAT submissions will be evaluated for compliance.

• The evaluation process is two-phased.

• Phase 1 focuses on Corporate Experience (Mission Focused).

• Phase 2 focuses on PWS & QASP, Past Performance, Price, Section 508, and Business Ethics/COI/Compliance.

• The Government may award without discussions.

• Not explicitly stated in this document.

• This solicitation does not commit the Government to pay for proposal preparation or submission costs.

• Offerors are advised to submit their best terms from a technical and price standpoint in their initial submission.

• The PWS must not exceed 20 pages (excluding QASP), and the QASP must not exceed 5 pages.

• Section 508 compliance requires submission of an Accessibility Conformance Report (ACR) / Voluntary Product Accessibility Template (VPAT).

• Business Ethics, Conflicts of Interest (COI), and Compliance require submission of a "Contractor/Offeror Conflict of Interest" attachment.

Form / Attachment / Pricing Sheet

This document, FAR 52.212-5, outlines the Contract Terms and Conditions Required To Implement Statutes or Executive Orders for Commercial Products and Commercial Services. It specifies which FAR clauses are incorporated by reference into a contract.

• Paragraph (a): Lists mandatory FAR clauses for acquisitions of commercial products and services, including prohibitions on certain agreements, contracting for specific technologies (e.g., Kaspersky Lab, telecommunications equipment), and clauses related to protests and applicable law.
• Paragraph (b): Lists FAR clauses that the Contracting Officer may select for incorporation, covering areas such as subcontractor sales restrictions, contractor business ethics, whistleblower rights, reporting requirements, supply chain security, small business concerns (HUBZone, SDVOSB, WOSB, etc.), labor standards, and foreign purchases.
• Paragraph (c): Lists FAR clauses applicable to commercial services, including Service Contract Labor Standards, minimum wages, and paid sick leave.
• Paragraph (d): Addresses Comptroller General examination of records.
• Paragraph (e): Details which FAR clauses are required to be flowed down to subcontractors for commercial products and services, and which may be included optionally.

This document is crucial for bidders as it defines the mandatory and optional contract clauses that will govern the performance of the contract. Understanding these clauses is essential for assessing compliance requirements, potential risks, and overall feasibility of bidding on the opportunity. Bidders should pay close attention to the clauses marked with an 'x' or explicitly stated as incorporated, as these will directly impact their contractual obligations.

Form / Attachment / Pricing Sheet

This attachment establishes the estimated beneficiary quantities and fixed unit prices for specific CLINs. These figures are used to calculate firm-fixed prices that are subject to an annual prospective price adjustment, known as a "True-Up," as detailed in the Special Contract Requirements Section.

• Applicable CLINs: CLINs 0004, 0006, 0008, 0010, 0012, and 0014 are subject to prospective adjustment. CLIN 0002 is excluded.
• Unit Pricing Assumptions: Prices are firm-fixed monthly rates per unique beneficiary (PMPM) and apply to software services as defined in the PWS. Beneficiary counts are based on monthly processed unique beneficiaries.
• Estimated Quantities and Prices: A table provides estimated average monthly and annual beneficiaries, unit prices (PMPM), and calculated annual CLIN prices for CLINs 0004 through 0014, with periods of performance extending from 11/05/2027 to 11/04/2033. For CLIN 0004, the estimated average monthly beneficiaries are 33,564,990, and the estimated annual beneficiaries are 827,055,202, with Unit Price and Calculated Annual CLIN Price listed as TBD.
• True-Up Submission Requirements: Contractors must submit an updated version of this attachment in MS Excel format no later than 90 days before the end of the current performance period. This submission should include actual average monthly unique beneficiary counts, revised projected quantities for option periods, and recalculated prospective CLIN prices.

This document is crucial for bidders as it outlines the pricing structure and estimated volumes for key CLINs. Understanding these quantities and the True-Up mechanism is essential for developing accurate proposals and understanding potential price adjustments throughout the contract period. The TBD status for CLIN 0004's price indicates a key area for clarification or negotiation.

Solicitation / RFP / RFQ

This solicitation, "ClaimsCore," seeks to replatform the Centers for Medicare & Medicaid Services (CMS) Medicare Fee-for-Service (FFS) claims adjudication environment. The goal is to replace four legacy COBOL-based systems with a Commercial-Off-The-Shelf (COTS), configurable, interoperable claims processing platform. This platform aims to achieve sub-second adjudication, improve real-time fraud prevention, and ensure transparent interoperability through HIPAA X12 and FHIR/REST APIs. The program supports CMS strategic goals for cost deflation, transparency, and policy agility, consolidating separate systems (Part A, Part B, DME) into a unified solution.

• Replatforming of legacy COBOL-based FFS claims adjudication systems.

• Acquisition of a COTS, configurable, interoperable claims processing platform.

• Support for sub-second adjudication, real-time fraud prevention, and interoperability via HIPAA X12 and FHIR/REST APIs.

• Development and implementation of an Information System Security Plan.

• Compliance with Section 508 accessibility standards for Information and Communication Technology (ICT).

• Adherence to HIPAA Business Associate requirements for Protected Health Information (PHI).

• Contract Type: Firm Fixed Price (FFP)

• Period of Performance: Base period from May 2026 to November 2026, with seven option periods extending through November 2033.

• Proposal submission instructions are detailed in Attachment 3, "ClaimsCore Instructions to Offerors."

• Evaluation criteria are also detailed in Attachment 3.

• Offer Due Date: March 13, 2026, 11:00 AM EST.

• The acquisition is listed as "UNRESTRICTED."

• North American Industry Classification Standard (NAICS) code: 541512 (Size Standard: $30 Million).

• Key Government Points of Contact: Candace Straker (Contracting Officer) and Lauren Holsey (Contract Specialist).

• The solicitation incorporates FAR 52.212-1, 52.212-4, and 52.212-5 by reference, with addenda.

• Attachment 1 provides the Statement of Objectives (SOO).

• Attachment 6 details Beneficiary Quantities and Unit Pricing, relevant to the "True Up Clause" for CLINs 0004, 0006, 0008, 0010, 0012, and 0014.

Statement of Objectives (SOO)

The ClaimsCore program aims to re-platform Medicare Fee for Service claims processing by replacing legacy "Shared Systems" (MCS, FISS, DME) and the Common Working File (CWF) with a flexible, interoperable Software as a Service (SaaS) platform. The goal is to reduce administrative burden, improve the beneficiary experience, and enable near real-time adjudication and claims status.

• Replace Legacy Systems: Modernize core claims processing systems while maintaining uninterrupted operations.
• Enhance Transparency & Timeliness: Provide near real-time adjudication and claims status for beneficiaries and providers.
• Reduce Provider Burden: Increase transparency, automation, and revenue certainty for providers.
• Improve Payment Integrity: Enhance fraud, waste, and abuse detection and prevention.
• Increase Policy Agility: Enable faster implementation and testing of new payment models.
• Strengthen Security & Resilience: Achieve high availability (99.9% uptime) and robust security posture.

The project involves procuring a SaaS COTS platform and associated configuration and integration services. Key areas include:

• Proof of Concept (POC) Phase: Contractors will demonstrate their solutions in parallel with legacy systems, focusing on adjudication, integration with Tier 1 systems, user interfaces, configuration flexibility, and security compliance.

• Production Implementation: Incremental rollout across Medicare Administrative Contractor (MAC) jurisdictions.

• Integration: Connecting with numerous external systems (e.g., PECOS, HIGLAS, HETS) and data sources.

• Data Migration: Migrating decades of data from legacy systems.

• System Performance: Near real-time adjudication, 99.9% uptime, horizontal scalability.

• Architecture & Standards: Alignment with CMS enterprise architecture and standards.

• Deployment Models: SaaS hosted in vendor-owned or CMS cloud infrastructure.

• Security: Compliance with FISMA Moderate, FedRAMP requirements, and comprehensive cybersecurity controls.

• Data Rights: CMS retains ownership and unlimited rights to CMS data.

A challenge-based acquisition process with multiple phases: RFP, Proof of Concept (POC), and Production Implementation. Down-selection will occur after the POC phase.

Form / Attachment / Pricing Sheet

This document is Attachment J.2, a template for submitting Contractor/Offeror Conflict of Interest (COI) information. It is required in accordance with Solicitation/Contract Section H.1 and must be included with proposal submissions or during contract performance. A response is required even if no conflict exists.

• Organizational Structure: Requires high-level and internal organization charts, along with a narrative explanation of structure and ownership.
• Actual, Potential, and/or Apparent COIs and Financial Interests/Relationships: Requires disclosure of current/active and known future non-foreign contracts that may pose a COI, including details on the customer, contract number, period of performance, total value, type of COI (Actual, Potential, Apparent), and type of conflict (Unequal Access, Biased Ground Rules, Impaired Objectivity). It also requires disclosure of financial interests/relationships that cause COIs.
• COI Oversight Process: Description of how the contractor identifies and resolves organizational and personal COIs.
• Conflict of Interest Mitigation: A proposed mitigation plan for identified conflicts, including description, rationale, strategy, timelines, and monitoring plan.
• Personal Conflicts of Interest (PCI): Requires analysis of PCI Financial Disclosures for governing body members, principals, and key personnel. Specific financial details are not to be disclosed to the Government, but mitigation plans for identified PCIs must be provided.
• Subcontractors: Prime contractors/offerors must analyze their subcontractors' COI submissions, ensuring conflict-free performance and providing an analysis of mitigation strategies.

Bidders must complete and submit this template (or a comparable format) as part of their proposal to demonstrate compliance with conflict of interest requirements. Failure to provide the required information, even if no conflict exists, may impact proposal evaluation. The template guides bidders on the specific organizational and financial disclosures needed to address potential conflicts.

Form / Attachment / Pricing Sheet

This document is a Past Performance Questionnaire intended for use by references of offerors responding to Solicitation RFP-CMS-75FCMC26R0022– ClaimsCore. It is designed to gather feedback on the offeror's performance to aid the Centers for Medicare & Medicaid Services (CMS) in their evaluation process.

• Cover Letter: Provides context for the reference, explains the purpose of the questionnaire, and instructs the reference on how to complete and return it to CMS.
• Questionnaire Sections: Structured around agency goals: Customer Service, Financial Management, Operational Excellence, and Innovations.
• Rating Scale: A numerical scale from 0 (Unsatisfactory) to 4 (Exceptional), with a "Not Applicable" option.
• Justification: References are required to justify each rating with specific comments.
• Submission Instructions: Details on how to submit the completed questionnaire via email (preferred) or mail to CMS.

Bidders should ensure their identified references understand the importance of this questionnaire and complete it accurately and promptly. The feedback provided by references directly impacts the evaluation of the bidder's past performance, a significant factor in the source selection process for this RFP.