Supplemental Medical Review Contract

Statement of Work (SOW) / Performance Work Statement (PWS)

This Statement of Work (SOW) outlines the requirements for a Supplemental Medical Review Contractor (SMRC) to perform post-payment medical reviews (MR) and related activities. The primary goal is to lower improper payment rates and increase efficiencies in the Medicare Fee-for-Service (FFS) program, specifically for Medicare Parts A, B, and DMEPOS claims.

The SMRC will conduct nationwide post-payment medical reviews as directed by CMS. Key tasks include:

• Provider Compliance Group (PCG) Specialty Reviews for issues identified by Federal agencies (e.g., OIG, GAO).

• Program Integrity Reviews in collaboration with the Fraud Investigations Group (FIG) to identify fraud, waste, and abuse (FWA).

• Assessing compliance with Medicare's coding, coverage, billing, and payment requirements.

• Recommending recoupment or adjustments for improperly paid claims.

• Responding to fluctuations in project/task assignments and claim volume.

• The Contractor must maintain a 95% accuracy score or greater each month for all tasks.

• Medical review decisions must be made within 60 days of receiving requested claims, with notification to CMS within 75 days.

• The SMRC must provide services nationwide, supporting all fifty (50) states and six (6) territories.

• The Contractor must comply with all applicable laws, regulations, Medicare manuals, and CMS requirements.

• Strict adherence to CMS security and privacy language for Information Technology (IT) is required, including compliance with HIPAA and other relevant regulations.

• Collaboration with various internal CMS components and external entities (e.g., State Agencies, OIG, GAO, FBI, UPIC, MACs) is necessary.

• Key personnel requirements are detailed, including Project Manager, Assistant Project Manager, Contractor Medical Director, and Medical Review Managers.

• The Contractor must develop and maintain a public website and a secure web-based portal for provider access to review status and ADRs.

Sources Sought Notice / Request for Information

This Sources Sought Notice (SSN) from the Centers for Medicare & Medicaid Services (CMS) seeks to determine the capability and availability of small businesses to provide fee-for-service (FFS) medical review and related services for the traditional Medicare program. This includes Parts A, B, and DMEPOS programs, as well as Medicare claims appeals support services. The information gathered will help CMS decide on appropriate acquisition procedures, including potential set-asides for small businesses.

CMS plans to procure a Supplemental Medical Review Contractor (SMRC) to perform nationwide, post-payment medical review and related tasks to reduce improper payments and combat fraud, waste, and abuse. Key tasks include:

• Specialty Reviews for issues identified by federal agencies (OIG, GAO) and CMS data analysis.
• Program Integrity Reviews for comprehensive medical review of CMS requests, including provider-specific reviews and pattern validation.

Specific activities include research, data analysis, claim sampling, medical review strategy development, staff training, medical record requests, post-payment medical/coding review, coverage/coding/billing policy application, provider education, extrapolation of overpayments, appeals support (including ALJ hearings), call center support, record management, and work tracking. The contractor will also be responsible for a public website, provider portal, document imaging, and printing services.

The anticipated workload involves large volumes, with approximately 110,000 claims annually for Task 1 (PCG Specialty Reviews) and 50,000 claims annually for Task 2 (Program Integrity Reviews), dispersed across numerous projects.

Potential offerors must demonstrate knowledge, experience, and capability in:

• Operating similar healthcare medical review operations.

• Performing high-volume post-payment medical review for Medicare FFS claims.

• Conducting program integrity reviews to identify fraud, waste, and abuse.

• Adapting staffing to workload changes.

• Performing data analysis and claim scrubbing.

• Understanding Medicare coverage, coding, and billing criteria.

• High-volume document management.

• Analyzing Medicare claims data from various systems (CWF, UCM, IDR, etc.).

• Performing large-scale extrapolation and recalculation of overpayments.

• Providing appeals support up to the ALJ level.

• Conducting provider/supplier outreach and response services.

• Obtaining Authority to Operate (ATO) from CMS and meeting security requirements.

• Developing processes/interfaces with future CMS IT systems.

• Developing a specific provider portal.

• Working with Electronic Submission of Medical Documentation (eSMD) and EHRs.

• Coordinating with various agencies and stakeholders.

• Utilizing artificial intelligence for non-medical review tasks.

• Recognizing patient harm/safety/quality issues.

• Possessing strong writing skills for in-depth reports.

• Responses are due by 12:00 PM Eastern Standard Time on June 23, 2026.

• Submissions are electronic and limited to 10 pages.

• This is for informational and planning purposes only; no contract will be awarded from this notice.

• No questions will be entertained regarding this market research.

• Draft SMRC Statement of Work