Amendment 1 - Attachment 6 Beneficiary Quantities Claims and Unit Pricing.pdf
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- Attached to
- ClaimsCore Combined Synopsis/Solicitation
- Solicitation number
- 75FCMC26R0022
About this file
This is an attachment to a federal contract solicitation establishing the pricing methodology and beneficiary quantity estimates for Medicare Claims Processing Software services. The attachment applies to six CLINs (0004, 0006, 0008, 0010, 0012, and 0014) that are subject to annual prospective price adjustment under a True-Up clause, while CLIN 0002 is expressly excluded from adjustment. Offerors may propose pricing using either Beneficiary-Based (PMPM) methodology with firm-fixed monthly prices per unique beneficiary or Claims Volume-Based (Per Claim) methodology with firm-fixed prices per processed claim. For the initial period (CLIN 0004, 11/05/2027–11/04/2028), CMS estimates 33,564,990 average monthly beneficiaries or 95.3 million monthly claims volume; unit prices and calculated annual CLIN prices are marked as "TBD" pending offeror proposals. Quantities for subsequent option periods (CLINs 0006–0014) are marked as "XXXX" and will be populated during the True-Up process.
The contractor must submit updated versions of this attachment in MS Excel format no later than 90 days prior to the end of each performance period, reflecting actual average monthly beneficiary or claims counts and revised projections for forthcoming options. Submissions must include supporting basis of estimate documentation, historical volume trends, and identification of anticipated changes affecting pricing such as MAC cut-overs. Following CMS review, the Contracting Officer may adjust CLIN prices for subsequent option periods via unilateral modification, with all adjustments prospective only and no retrospective adjustments permitted for differences between estimated and actual volumes. The calculated annual CLIN price formulas are: (Estimated Average Monthly Beneficiaries × Unit Price × 12 Months) for PMPM pricing, or (Estimated Average Monthly Claims Volume × Unit Price per Claim × 12 Months) for per-claim pricing.
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Attachment 6 – True-Up: Beneficiary Quantities, Claims Volume, and Unit Pricing for Medicare Claims Processing Software
1. Purpose This Attachment establishes the estimated beneficiary quantities, estimated claims volume, and fixed unit prices used to calculate the firm-fixed prices for the CLINs subject to the annual prospective price adjustment (“True-Up”) as described in Special Contract Requirements Section, True-Up Clause, of this Contract.
Offerors may propose pricing using one of the following methodologies:
• Beneficiary-Based (PMPM) Pricing
• Claims Volume-Based (Per Claim) Pricing
2. Applicable CLINs The beneficiary quantities, claims volume, and unit prices identified in this Attachment apply solely to the following CLINs, which are subject to prospective adjustment:
- CLIN 0004
- CLIN 0006
- CLIN 0008
- CLIN 0010
- CLIN 0012
- CLIN 0014
The following CLINs are expressly excluded from adjustment under the True-Up Clause and are not reflected in the calculations herein:
- CLIN 0002
3. Unit Pricing Assumptions
- Unit prices are firm-fixed monthly prices per unique beneficiary (i.e., Per Member / Per Month (PMPM)) or price per claim processed.
- Prices apply to software services as defined in the Performance Work Statement (PWS).
- Beneficiary counts are based on unique beneficiaries per month processed through the Contractor’s software system.
- Claims counts are based on unique claims received per month processed through the contractor software systems.
4. Estimated Beneficiary Quantities and Unit Prices The tables below identify the estimated beneficiary quantities and unit prices applicable to the CLINs subject to adjustment.
A. Beneficiary-Based Pricing (PMPM)
Unit prices shall be firm-fixed monthly prices per unique beneficiary.
Calculated Annual CLIN Price Formula:
Estimated Average Monthly Beneficiaries × Unit Price × 12 Months
B. Claims Volume-Based Pricing (Per Claim) Unit prices shall be firm-fixed prices per processed claim.
Annual CLIN Price Formula:
Estimated Average Monthly Claims Volume × Unit Price per Claim × 12 Months
5. Annual True-Up Submission Requirements In accordance with the True-Up Clause, the Contractor shall submit an updated version of this Attachment in MS Excel format no later than 90 days prior to the end of the current period of performance, reflecting:
- Actual average monthly unique beneficiary counts for the current period
- Revised projected beneficiary quantities or claims volume for all forthcoming option periods (for informational purposes only).
- Recalculated prospective CLIN prices using the fixed unit rates identified herein
The revised Attachment shall be accompanied by:
- Supporting basis of estimate for projected beneficiary or claim volumes
- Historical beneficiary or claim volume trends from the current period of performance
- Identification of any anticipated changes in beneficiary population or claim volume that may impact pricing (e.g., MAC cut-overs)
6. Price Adjustment Process Following CMS review of the submitted report and revised Attachment 6, the Contracting Officer may adjust the prices of the applicable CLINs for the subsequent option period via unilateral modification. All adjustments will be prospective only. No retrospective price adjustments will be made for differences between estimated and actual beneficiary quantities or claims volume.
Table 1: Estimated Beneficiary Quantities and Unit Prices Table
CLIN Period of Performance Estimated Avg.
Monthly Beneficiaries*
Unit Price
(PMPM)
Calculated Annual
(extended) CLIN Price
0004 11/05/2027 –11/04/2028 33,564,990 TBD TBD
0006 11/05/2028 – 11/04/2029 XXXX XXXX XXXX
0008 11/05/2029 – 11/04/2030 XXXX XXXX XXXX
0010 11/05/2030 – 11/04/2031 XXXX XXXX XXXX
0012 11/05/2031 – 11/04/2032 XXXX XXXX XXXX
0014 11/05/2032 – 11/04/2033 XXXX XXXX XXXX
*For the solicitation/proposal purposes, CMS is using a 2025 monthly National Average.
Table 2: Estimated Claim Volume and Unit Prices Table
CLIN Period of Performance Estimated Monthly
Claims Volume
Unit Price (Per Claim)
Calculated Annual Price
0004 11/05/2027 –11/04/2028 95.3 M TBD TBD
0006 11/05/2028 – 11/04/2029 XXXX XXXX XXXX
0008 11/05/2029 – 11/04/2030 XXXX XXXX XXXX
0010 11/05/2030 – 11/04/2031 XXXX XXXX XXXX
0012 11/05/2031 – 11/04/2032 XXXX XXXX XXXX
0014 11/05/2032 – 11/04/2033 XXXX XXXX XXXX
| Attachment 6 – True-Up: Beneficiary Quantities, Claims Volume, and Unit Pricing for Medicare Claims Processing Software |
| 1. Purpose |
| 2. Applicable CLINs |
| 3. Unit Pricing Assumptions |
| 4. Estimated Beneficiary Quantities and Unit Prices |
| 5. Annual True-Up Submission Requirements |
| 6. Price Adjustment Process |
| Table 1: Estimated Beneficiary Quantities and Unit Prices Table |
| Table 2: Estimated Claim Volume and Unit Prices Table |
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