Attachment J.03 Past Performance Questionnaire.docx

RFP#75FCMC18R0010 Past Performance Questionnaire Attachment J.03

PERFORMANCE QUESTIONNAIRE

Sample Cover Letter

[COMPANY LETTERHEAD (Prime or subcontractor)]

Reference Name, Address and Contact information Date

SUBJECT: 75FCMC18R0010 – Pricing, Data Analysis, and Coding (PDAC)

Dear _________________:

We are currently responding to the Centers for Medicare & Medicaid Services (CMS) Request for Proposal number 75FCMC18R0010 (as a subcontractor to______ (If applicable)). The purpose of this contract is to perform ____________________________________________.

There is an increased emphasis on past performance in the federal source selection process. The CMS is requesting that customers and clients of Offerors provide the information as described within the attached questionnaire and return it to them for evaluation. We have identified you as one of our references and respectfully request that you complete and sign the attached questionnaire and then return it to CMS.

Questionnaires are due to CMS no later than ____________ (to be filled in by Offeror); however, we would appreciate an earlier response if at all possible.

We sincerely appreciate your cooperation in this matter.

Sincerely, Reference Name Title

DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop B3-30-03 Baltimore, Maryland 21244-1850

Office of Acquisition and Grants Management

SUBJECT: Solicitation 75FCMC18R0010 – Pricing, Data Analysis, and Coding (PDAC)

To Whom It May Concern:

The Centers for Medicare & Medicaid Services (CMS) very much appreciates your time and thoughtfulness in completing the attached questionnaire. The information obtained from this questionnaire will be utilized to evaluate the past performance of Offerors/Contractors who wish to be awarded a contract with CMS.

CMS may engage in exchanges with offerors regarding past performance information submitted to CMS in connection with the subject solicitation. If CMS engages in such exchanges, CMS may share information disclosed in this survey with the Offeror to whom it pertains, as permitted or required by the FAR. Otherwise, CMS will only share information from this survey outside the agency pursuant to a protective order or as otherwise required by law

The questionnaire is arranged by general performance areas, e.g., quality of service / performance, cost control, timeliness, management, etc. Each area consists of a few basic questions relating to these aspects of performance with regard to the Offeror/Contractor with which you worked. Please complete the questionnaire as indicated on the form.

Finally, please sign your name and identify your position during your association with the referenced Offeror/Contractor. Once completed, please submit the questionnaire electronically to kristopher.cyrus@cms.hhs.gov and copy amy.duckworth@cms.hhs.gov.

Thank you for taking the time to complete the questionnaire.

Sincerely,

PAST PERFORMANCE QUESTIONNAIRE

CMS Solicitation No. 75FCMC18R0010

(Company Being Evaluated) (Offeror)

Name of Contracting Activity:____________________________________________________ Brief Description of Work: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Contract Type:________________________________________________________________________ Total Contract Value:___________________________________________________________________ Performance Period:____________________________________________________________________ Please complete the following questionnaire about the Offeror/Contractor and indicate your responses in the blocks or columns, as appropriate. Numerical ratings are as indicated in the Rating Scale below. Other Ratings are as indicated in each block.

Rating Scale:

We request that you justify each of your ratings with a comment. Please be as specific in your comment as possible, especially in situations that warrant very high or very low ratings. Use extra pages as necessary or expand the form electronically as needed.

CUSTOMER SERVICE

How did the contractor work collaboratively with the “customers” of the contract?

“Customers” may include, but are not limited to, other stakeholders (such as Medical Providers in a health insurance contract) critical to the success of the contract in question and those members of your staff responsible for the administration of the contract.

If there are any instances that are of particular note, either positive or negative, please give specifics around the citation.

Is/was the contractor committed to customer satisfaction and would you hire this contractor again?

If there are any instances that are of particular note, either positive or negative, please give specifics around the citation.

Comments:

FINANCIAL MANAGEMENT

Was the contractor timely and accurate in processing payments if the contractor administered funds and/or payments for services?

If the contractor administered funds and/or payments on this contract, was the contractor timely and accurate in submitting accounting reports?

If there are any instances that are of particular note, either positive or negative, please give specifics around the citation.

OPERATIONAL EXCELLENCE

How was the contractor’s quality of products/services? How well did the contractor meet the standards and requirements of the contract’s Statement of Work? Was the contractor timely in meeting its contract schedule and/or requirements?

If there are any instances that are of particular note, either positive or negative, please give specifics around the citation.

How well did the contractor utilize internal controls to effectively manage its staff and systems?

If there are any instances that are of particular note, either positive or negative, please give specifics around the citation.

INNOVATIONS

How well did the contractor develop and continually refine its internal business processes to improve the quality of the work delivered on the contract?

If the contractor did incorporate internal business processes changes, what was the impact of those changes on the daily operations?

If there are any instances that are of particular note, either positive or negative, please give specifics around the citation.

Agency/Company COMPLETING Questionnaire

Agency/Company Name: ___________________________

Address: ___________________________

Signature of Individual Completing the Questionnaire: ____________________________________ Date

Name: ___________________________ Telephone No.: ________________________

Title: ___________________________ Email Address: ________________________

<OR>

Q1. Quality: Did the Offeror demonstrate the execution of quality efforts resulted in effective performance outcomes for work activities?

Q2. Cost Control: Did the Offeror demonstrate the ability to ensure costs were within budget?

Q3. Schedule: Did the Offeror demonstrate the ability to consistently meet project milestones and deliverables on time?

Q4. Management: Did the Offeror demonstrate a past track record of notifying its contractors/customers of problems, remaining flexible and reliable, and being responsive to contract requirements and recommending solutions? How well did the Offeror match the qualifications of the key position, as described in the contract, with the person that filled the key position? Did the Offeror support key personnel so they were able to work effectively?

Q4. Utilization of Small Business: Did the Offeror demonstrate and implement an effective and efficient small/small disadvantaged business subcontracting plan?

Agency/Company COMPLETING Questionnaire

Agency/Company Name: ___________________________

Address: ___________________________

Signature of Individual Completing the Questionnaire: ____________________________________ Date

Name: ___________________________ Telephone No.: ________________________

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