ClaimsCore Combined Synopsis/Solicitation

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.