Exhibit_E.6___Past_Performance_Questionnaire.docx

PEO IDIQ PAST/PRESENT PERFORMANCE QUESTIONNAIRE

When filled in this document is considered Source Selection Information – See FAR 2.101 and 3.104

SAMPLE PAST PERFORMANCE QUESTIONNAIRE COVER LETTER

LETTERHEAD

(Date)

FOR OFFICIAL USE ONLY

The Centers for Medicare & Medicaid Services (CMS) is in the process of selecting contractors for the Provider Enrollment and Oversight Multiple Award Contract (PEO MA IDIQ). CMS is responsible for enrolling all providers/suppliers into the Medicare program that meet the standards and requirements. In addition, PEOG must ensure that providers/suppliers that seek to defraud the government through Medicare are kept out of the program.

One of the considerations in proposal evaluation is the verification of the Offeror's past and present performance on contracts, which reflect the Offeror's ability to perform on the proposed effort. We depend on information received from agencies such as yours, which have had firsthand experience with an Offeror, for the evaluation of the Offeror's performance on those contracts.

Our areas of interest in the Offeror are summarized in the enclosed questionnaire. Our schedule is extremely tight and we need your written response no later than _______ calendar days after your receipt of this letter. This schedule will allow us sufficient time to analyze the data prior to the start of negotiations.

To assist you in preparing your response and expediting your reply, the questionnaire must be filled out electronically and emailed to PEO2018@cms.hhs.gov. Please call Mr. David Hochendoner at 410-786-6648 or Mr. Justin Menefee at 4410-786-7629 if you have any questions. Your completed questionnaire will become a part of the official Source Selection records, and the Government may contact you to discuss your inputs.

Your assistance is greatly appreciated and your prompt response will be one of the keys to the successful and timely completion of this Source Selection.

//signed/ss// Gina Romano Contracting Officer

1 Atch: Past Performance Questionnaire

SECTION 1: CONTRACT IDENTIFICATION

1. Contractor:

1. DUNS of contractor contract was awarded to:

1. Role (check): Prime Subcontractor Teaming Partner Joint Venture Partner Other (specify)

If subcontractor, partner or other, who is the Prime?

1. Contract Number:

1. Contract Vehicle: (IDIQ Contract, IDIQ Task Order)

1. Contract Type: (CPFF, CPIF, CPAF, FFP, T&M, Other)

1. Was this a competitive contract? Yes _____ No _____

1. Period of performance:

1. Initial contract cost: $

1. Current/final contract cost: $

1. Reasons for differences between initial contract cost and final contract costs:

1. Description of service provided:

SECTION 2: CUSTOMER OR AGENCY IDENTIFICATION

1. Customer or agency name:

1. Customer or agency description (if applicable):

1. Geographic description of services under this contract, i.e. local, nationwide, worldwide:

SECTION 3: EVALUATOR IDENTIFICATION

1. Evaluator's name:

1. Evaluator's title:

1. Evaluator's phone and email:

1. Number of years evaluator worked on subject contract:

SECTION 4: EVALUATION

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 ratings within each category with a summary narrative afterwards. 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.

FOR EACH OF THE FIVE (5) SEPARATE FACTORS AND THEIR ASSOCIATED QUESTIONS LISTED BELOW, IDENTIFY WITH AN “X” IN THE APPROPRIATE BLOCK USING THE SCALE PROVIDED TO THE RIGHT OF EACH QUESTION.(Scale defined above)

T-1. Did the Offeror demonstrate a thorough understanding of the nature of the work required and the disciplines required to accomplish them?

T-2. Did the Offeror demonstrate the execution of quality efforts resulted in effective performance outcomes for work activities?

T-3. Did the Offeror demonstrate the ability to adapt to changes in task order/contract requirements or changes in priority?

T-4. Did the Offeror demonstrate the ability in identifying and mitigating risks?

T-5. Did the Offeror demonstrate the ability to deal with problems and implement corrective actions?

T-6. Did the Offeror establish and maintain an effective quality assurance program and meet quality improvement requirements?

T-7. Did the Offeror provide accurate reports/data?

Please provide a summary of the Technical ratings you provided paying particular attention to the definitions provided above for E (Exceptional), V (Very Good), S (Satisfactory), M (Marginal) or U (Unsatisfactory) in response to the questions above (use additional sheets, if necessary).

Summary of the Technical Performance:

Summary Narrative for Technical:

2) Management Approach

MA-1. Effectiveness of overall contract management and the ability to manage a large contract and a large team or; responded to, executed, and managed a large volume of orders effectively.

MA-2. Ability to plan, control, monitor, and report cost, schedule and performance metrics.

MA-3. Ability to recruit, staff, retain, train, and replace qualified employees.

MA-4. Ability to identify, mitigate, and manage organizational conflicts of interest and other performance risks.

MA-5. Ability in identifying key positions, filling these positions with individuals with the necessary skills, and providing backups.

Please provide a summary of the Management ratings you provided paying particular attention to the definitions provided above for E (Exceptional), V (Very Good), S (Satisfactory), M (Marginal) or U (Unsatisfactory) in response to the questions above (use additional sheets, if necessary).

Summary Narrative for Management Approach:

S-1. Met small business goals set forth in the approved small business subcontracting plan or small business participation plan, if applicable.

S-2. Subcontracted with small businesses for technical performance roles.

Please provide a summary of the Small Business ratings you provided paying particular attention to the definitions provided above for E (Exceptional), V (Very Good), S (Satisfactory), M (Marginal) or U (Unsatisfactory) in response to the questions above (use additional sheets, if necessary).

Summary Narrative for Small Business Utilization:

C-1. Forecasted contract costs accurately.

C-2. Performed within forecasted contract costs.

C-3. Alerted Government of unforeseen costs before they occur.

C-4. Sufficiency and timeliness of cost and status reporting.

Please provide a summary of the Cost ratings you provided paying particular attention to the definitions provided above for E (Exceptional), V (Very Good), S (Satisfactory), M (Marginal) or U (Unsatisfactory) in response to the questions above (use additional sheets, if necessary).

Summary Narrative for Cost Performance:

S-1. Did the Offeror demonstrate the ability to consistently meet project milestones and deliverables on time?

S-2. Did the Offeror alert the Agency if it was not going to meet the milestone or deliverable date?

Please provide a summary of the Schedule ratings you provided paying particular attention to the definitions provided above for E (Exceptional), V (Very Good), S (Satisfactory), M (Marginal) or U (Unsatisfactory) in response to the questions above (use additional sheets, if necessary).

Summary Narrative for Schedule:

3. Government Contracts Only: Has/was this contract been partially or completely terminated for convenience or default or are there any pending terminations?

Yes___ No____

Convenience___ Default___ Pending Terminations___

If yes, please explain (e.g., inability to meet cost, performance, or delivery schedules, etc.).

SECTION 5: NARRATIVE SUMMARY

Would you have any reservations about soliciting this contractor in the future or having them perform one of your critical and demanding programs?

Do you know of another source that has knowledge of this contractor’s performance?

Name / Company:

Phone Number:

Please provide any additional comments concerning this contractor’s performance, as desired.

Evaluator’s Signature Date

Thank you for your prompt response and assistance!

Please return this completed questionnaire via email to PEO2018@cms.hhs.gov