ClaimsCore Request for Information

Form / Attachment / Pricing Sheet

This document is a template for contractors and offerors to submit information regarding potential, actual, or apparent Conflicts of Interest (COI) as required by Solicitation/Contract Section H.1. A response is mandatory, even if no conflict exists. The template is a sample, and offerors may use their own format provided it captures the required information.

• Offeror/Contractor Information: Name, date submitted, submission type (initial or revised), Solicitation #, Contract #.
• Corporate and Organizational Structure: High-level and internal organization charts, and a narrative explanation of structure/ownership.
• Actual, Potential, and/or Apparent COIs and Financial Interests/Relationships:
  • Description of COI oversight process.
  • Disclosure of contracts that could pose a COI (including prime, subcontracts, parent, and affiliates), detailing customer, contract #, period of performance, total value, type of COI (Actual, Potential, Apparent), and type of conflict (UA, BG, IO).
  • Disclosure of financial interests/relationships that cause a COI, detailing the entity, type of COI, and a description of the interest/relationship.
  • Proposed mitigation plan for identified COIs, including description, rationale, strategy, timeframes, and monitoring plan.
• Personal Conflicts of Interest (PCI): While not disclosed to the government, offerors must analyze PCIs for principals and key personnel, considering assets, income, liabilities, and reimbursements/gifts. Mitigation plans for identified PCIs should be provided in the COI section (B.4) without individual names.
• Subcontractors: Prime contractors must analyze subcontractor COI submissions, ensuring they meet criteria, identifying and analyzing mitigation strategies, and recommending acceptability to the Contracting Officer.

Bidders must use this template or a similar format to disclose any organizational or personal conflicts of interest related to the opportunity. Failure to provide adequate COI information, including proposed mitigation strategies, may impact proposal evaluation and contract award. This document is critical for understanding compliance requirements and demonstrating a conflict-free performance capability.

Solicitation / RFP / RFQ

This solicitation is for the Centers for Medicare & Medicaid Services (CMS) to replatform its 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 improve sub-second adjudication, enhance real-time fraud prevention, and provide transparent interoperability through HIPAA X12 and FHIR/REST APIs. The program supports CMS strategic goals for cost deflation, transparency, and policy agility, consolidating existing systems into a unified solution.

• Acquire a COTS, configurable, interoperable claims processing platform.

• Achieve sub-second adjudication.

• Implement improved real-time fraud prevention.

• Ensure transparent interoperability through HIPAA X12 and FHIR/REST APIs.

• Support CMS strategic goals for cost deflation, transparency, and policy agility.

• Consolidate existing systems (Part A, Part B, DME) into a unified solution.

• Contract Type: Firm Fixed Price (FFP)

• Period of Performance: Base Period (Proof of Concept) from 01 SEP 2026 to 30 NOV 2026, with seven (7) option years extending through 30 NOV 2033.

• Offer Due Date: 1/23/2026, 11:00 AM EST.

• Submission Instructions: Refer to Attachment 3, Proposal Instructions and Evaluation Criteria.

• Evaluation Criteria: Refer to Attachment 3, Proposal Instructions and Evaluation Criteria.

• This acquisition is Unrestricted.

• NAICS Code: 541512

• Size Standard: $8.0 Million

• The solicitation includes numerous FAR and HHSAR clauses covering areas such as:

  • Contractor Work Performed Outside the United States
  • Government Representatives and Responsibilities
  • Payments and Invoices
  • Information Technology Security Requirements
  • Information and Communication Technology Accessibility
  • HIPAA Business Associate Clause
  • Conflicts of Interest
  • Representations and Certifications

• Attachments include:

  • Attachment 1 - Draft ClaimsCore Statement of Objectives
  • Attachment 2 - Contractor COI Submission Template
  • Attachment 3 - ClaimsCore Instructions to Offerors
  • Attachment 4 - Past Performance Questionnaire
  • Attachment 5 - FAR 52.212-5

Statement of Objectives (SOO)

The ClaimsCore program aims to modernize Medicare Fee-for-Service claims processing by replacing legacy "Shared Systems" (Multi-Carrier System, Fiscal Intermediary Shared System, Durable Medical Equipment Claims System) and the Common Working File (CWF) with a flexible, interoperable Software as a Service (SaaS) platform. The goal is to improve efficiency, enhance beneficiary experience, reduce provider burden, and strengthen fraud prevention.

Key objectives include:

• Replacing FISS, MCS, DME, and CWF while maintaining uninterrupted operations.

• Enhancing the beneficiary experience with sub-second adjudication and faster EOBs.

• Reducing provider burden through increased transparency and consistency.

• Improving fraud, waste, and abuse (FWA) detection and prevention.

• Enabling policy agility and flexibility for faster implementation of new payment models.

• Ensuring high availability (99.9% uptime) and scalability.

• Providing robust Disaster Recovery (DR) and Business Continuity Plans (BCP).

• Ensuring interoperability via HIPAA X12, REST/FHIR APIs.

• Target 99.9% uptime.

• Sub-second adjudication times.

• Specific metrics for Proof of Concept (POC) phase include claim-level outcome alignment (≥95%), historical data migration error rate (≤0.2%), and adjudication latency (p95 ≤1s, p99 ≤2s).

• Not explicitly defined in this SOO, but implies a long-term operational requirement.

• Work will be performed within the CMS Amazon Web Services (AWS) Cloud.

• Preference for Commercial Off-The-Shelf (COTS) SaaS platforms.

• Emphasis on configuration over custom code.

• Strict adherence to CMS enterprise architecture, security (FISMA Moderate, Zero Trust), and accessibility (Section 508) standards.

• Data rights and licensing must align with government needs, avoiding vendor lock-in.

• Solutions must be deployable in the CMS AWS Cloud.

• A challenge-based acquisition approach with a Proof of Concept (POC) phase is planned.

Solicitation / RFP / RFQ

This document provides instructions to offerors for a solicitation, outlining the requirements for submitting quotations or proposals. It clarifies that the Government is not committed to paying for proposal preparation costs and that the procurement is subject to future fund availability.

• Response Format: Submissions should be in Microsoft Office or Adobe Acrobat compatible formats, formatted for letter-sized pages (8-1/2 x 11"), single-spaced, with 1-inch margins. Digital submissions should be page-numbered consecutively. Page limitations may 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, etc., acceptable in 9-point single-spaced font. Tables should be formatted for searchability, avoiding images of text.

• Electronic Mail Size Limit: Keep attachments below 25MB.

• Written Questions: Submit via e-mail by a specified date and time (TBD), referencing specific RFP sections. CMS may not answer late questions. CMS may elect not to answer questions or conduct Q&A sessions. Answers may be shared with all offerors.

• Submission: Proposals must be submitted via email to specified contacts by the RFP closing date (TBD) at 11:00 a.m. ET. Offerors must cite DUNS and SAM EIN numbers. Late responses will not be considered.

• Evaluation: Proposals will be evaluated using a tradeoff process to determine Best Value. All factors other than cost or price combined are significantly more important than cost or price. Awards are estimated for two (2) to four (4) entities.

• Two-Phase Evaluation:

  • Phase 1: Evaluation of Corporate Experience (Mission Focused). Limited to five pages. Focuses on recent, relevant experience in specific areas: high-volume cloud-based claims processing, automated rule mining, fraud detection, professional services capacity, and financial scale/stability.
  • Phase 2: Evaluation of Performance Work Statement (PWS) & Quality Assurance Surveillance Plan (QASP), Past Performance, and Price. Section 508, Business Ethics, Conflicts of Interest (COI), and Compliance will also be evaluated but not for best value.

• PWS/QASP Requirements: The PWS should detail the proposed solution, tasks, deliverables, staffing, methods, assumptions, exclusions, and exceptions. It must disclose planned use of AI and any used/reconditioned supplies. The PWS must not exceed 20 pages, and the QASP must not exceed 5 pages.

• Past Performance: Offerors and significant subcontractors must disclose past performance information within the last three years, including CMS contracts, relevant government/commercial contracts, and specific details for each. Past Performance Questionnaires (PPQs) may be used.

• Price: Includes a narrative (cover letter, Basis of Estimate) and a spreadsheet. The Basis of Estimate should detail the estimating methodology, labor, materials, and ODCs. Pricing must be fair and reasonable. Subcontractor pricing details are required.

• Section 508: Offerors must comply with HHS ICT accessibility standards and submit an Accessibility Conformance Report (ACR) based on the VPAT. Non-compliance remediation is at the contractor's expense.

• Business Ethics & COI: Submit the "Contractor/Offeror Conflict of Interest" attachment. Subcontractor COI analysis is required.

• The Government may award without discussions. Initial proposals should represent the offeror's best terms.

• The PWS and draft QASP submitted will be incorporated into the contract and become government property.

• Section 508 and COI evaluations apply only to the apparent successful offeror and are not part of the best value determination.

Form / Attachment / Pricing Sheet

This document, FAR 52.212-5, outlines the Contract Terms and Conditions Required To Implement Statutes or Executive Orders for the acquisition of commercial products and commercial services. It specifies which FAR clauses are incorporated by reference and must be complied with by the contractor.

This clause is divided into several sections:

• Paragraph (a): Lists mandatory FAR clauses for commercial products and services.
• Paragraph (b): Lists FAR clauses that the Contracting Officer may indicate as incorporated by reference, with specific clauses checked as applicable (e.g., 52.203-6, 52.203-13, 52.209-6, 52.219-8, 52.222-26, 52.222-35, 52.222-36, 52.222-37, 52.225-1, 52.226-8, 52.224-3).
• Paragraph (c): Lists FAR clauses applicable to commercial services that the Contracting Officer may indicate as incorporated by reference.
• Paragraph (d): Outlines Comptroller General examination of records requirements for certain contracts.
• Paragraph (e): Specifies which clauses are required to be flowed down to subcontracts for commercial products and commercial services, and which are optional.

Bidders must review the checked clauses in paragraphs (b) and (c), and the flow-down requirements in paragraph (e), to understand their contractual obligations and compliance requirements. This includes adherence to various statutes and executive orders related to ethics, labor, small business utilization, supply chain security, and other areas. Failure to comply with these incorporated clauses can impact proposal evaluation and contract performance.

Form / Attachment / Pricing Sheet

This document is a Past Performance Questionnaire provided by the Centers for Medicare & Medicaid Services (CMS) for Solicitation RFP-CMS-75FCMC26R0022– ClaimsCore. It is intended for use by customers and clients of offerors to provide feedback on their past performance.

• Company Being Evaluated: Section to identify the Offeror/Contractor.
• Brief Description of Work, Contract Type, Total Contract Value, Performance Period: Fields to detail the contract being referenced.
• Rating Scale: Defines numerical ratings from 0 (Unsatisfactory) to 4 (Exceptional), with N/A option.
• Questionnaire Sections: Covers Customer Service, Financial Management, Operational Excellence, and Innovations, with specific questions and space for comments and ratings in each.
• Agency/Company Completing Questionnaire: Section for the reference to provide their contact information and signature.

Offerors responding to RFP-CMS-75FCMC26R0022– ClaimsCore should identify references who can complete this questionnaire. The feedback provided by these references will be used by CMS to evaluate the offeror's past performance, which is an emphasized factor in the source selection process. Bidders should ensure their references are aware of the contract details and the due date for submission, which is to be filled in by the offeror. The completed questionnaire should be returned to CMS via email or mail as specified.