Request for Information for the Supplemental Medical Review Contractor (SMRC)

Statement of Work (SOW)

This Statement of Work (SOW) outlines the requirements for a Supplemental Medical Review Contractor (SMRC) to perform medical reviews and related activities for the Centers for Medicare & Medicaid Services (CMS). The primary goal is to reduce improper payment rates and increase the efficiency of medical review functions, primarily for Medicare Fee-for-Service (FFS) claims.

The SMRC will support three main initiatives within CMS's Center for Program Integrity (CPI):

• Task 1: Provider Compliance Group (PCG) Specialty Reviews: Addressing issues identified by federal agencies (OIG, GAO) and CMS internal data analysis programs (CERT, FATHOM, PEPPER).
• Task 2: Program Integrity Reviews: Supporting program integrity efforts through medical reviews.

The SMRC will conduct large-volume nationwide medical reviews on Medicare FFS claims (Parts A, B, and DMEPOS), assessing compliance with coding, coverage, billing, and payment requirements. Reviews may involve up to 300,000 claims per project. The SOW also details numerous other tasks, including non-medical record reviews, research, data analysis, claim re-reviews, public website maintenance, record management, customer support, defending decisions at ALJ hearings, and a telehealth project under the Consolidated Appropriations Act (CAA).

• Timely completion of medical reviews and submission of reports as per specified timeframes (e.g., 30-day decision for Task 1, 60-day decision for Task 2).
• Adherence to IT and security requirements, including obtaining Authority to Operate (ATO) within 60 days of award.
• Maintenance of confidentiality of medical records.
• Regular reporting, including monthly status reports and final project reports.
• Quality assurance processes to ensure accuracy and inter-reviewer reliability.

Performance is expected nationwide, covering all fifty states and six territories. The SOW does not specify a fixed period of performance but outlines requirements for transition-in and close-out activities.

• Collaboration: Must coordinate with various entities including State Agencies, investigative agencies (OIG, FBI), other CMS contractors (UPIC, MACs), and professional organizations.
• IT & Security: Strict adherence to CMS IT security requirements, including Business Partner System Security Manual (BPSSM) and CMS Information Security (IS) Acceptable Risk Safeguards (ARS).
• Data Use Agreements (DUA): Contractors requiring access to Protected Health Information (PHI) and/or Personally Identifiable Information (PII) must execute DUAs.
• Personnel: Key personnel include Project Manager, Assistant Project Manager, Medical Director, Medical Review Manager, Senior Statistician, and Customer Service Manager, each with specific experience and education requirements. All personnel must meet Medicare program standards.
• Reporting: Comprehensive reporting requirements are detailed for each task, including initial project reports, final project reports, monthly status reports, and specific deliverables for tasks like research and data analysis.

Request for Information (RFI)

This RFI is issued by the Centers for Medicare & Medicaid Services (CMS) for market research purposes. CMS is seeking industry input on the feasibility and recommended approaches for implementing fixed-price pricing structures for the Supplemental Medical Review Contractor (SMRC) Statement of Work (SOW). The goal is to inform acquisition planning and determine if a fixed-price or hybrid pricing model would be advantageous for the SMRC SOW.

The SMRC SOW involves a broad range of activities including:

• Medical record review and claim adjudication for improper payments and program integrity.
• Discussion and Education (D&E) sessions with providers.
• Reporting and performance metrics.
• Annual Performance Assessment (APA) support.
• Quality Control Plan (QCP) development and maintenance.
• IT systems setup and maintenance.
• Start-up/ramp-up activities.
• Record management and work tracking dashboard.
• Website development and maintenance.
• Administrative Law Judge (ALJ) hearing support. Optional tasks include fraud referral support, public portal development, innovation projects, and statistical extrapolation of overpayments.

CMS requests information on:

• Contractor Information: Company details, POC, business size, and relevant experience.

• Fixed-Price Feasibility Assessment: Assessment of Firm Fixed Price (FFP) appropriateness, recommendations for hybrid approaches, risk allocation, and strategies for volume variability.

• Proposed Pricing Structure: Recommended pricing for each task area, staffing, labor categories, performance standards, carryover costs, and Section 508 compliance costs.

• Additional Recommendations: Any other relevant best practices or innovative pricing approaches.

• Issue Date: April 9, 2026

• Response Due Date: April 16, 2026, 5:00 PM Eastern Time

• This RFI is for information and planning purposes only and does not constitute a solicitation.

• No payment will be made for information provided in response to this RFI.

• Responses should be submitted electronically in Microsoft Word (.docx) or Adobe PDF format, with a maximum of 20 pages.