Attachment 4 - Past Performance Questionnaire.docx
DOCX document 58 KB Posted
- Attached to
- ClaimsCore Combined Synopsis/Solicitation
- Solicitation number
- 75FCMC26R0022
About this file
This is a Past Performance Questionnaire template for RFP-CMS-75FCMC26R0022 (ClaimsCore), issued by the Centers for Medicare & Medicaid Services. The document provides instructions and a standardized form for customers and clients of offerors to evaluate contractor past performance. References must complete the questionnaire and return it to CMS by a deadline specified by the offeror, with submission options including email to Candace.Straker@cms.hhs.gov or Lauren.Holsey@cms.hhs.gov, or mailed to the Office of Acquisition and Grants Management in Baltimore, Maryland. CMS advises that information disclosed in the survey may be shared with relevant offerors as permitted by the Federal Acquisition Regulation and will otherwise be protected.
The questionnaire evaluates performance across four agency goal areas: Customer Service, Financial Management, Operational Excellence, and Innovations and Technology. References rate contractor performance on a five-point scale ranging from 0 (Unsatisfactory) to 4 (Exceptional), with ratings for specific criteria including contractor collaboration with stakeholders, customer satisfaction, payment processing timeliness and accuracy, accounting report submission, quality of products and services, compliance with Statement of Work standards, schedule adherence, internal controls effectiveness, and development of improved business processes. Respondents must provide detailed comments justifying each rating and identify themselves by name, title, agency/company, contact information, and signature. This questionnaire is a standard evaluation tool and does not contain specific solicitation requirements or pricing terms.
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RFP-CMS-75FCMC26R0022
Attachment J-4 Past Performance Questionnaire
PERFORMANCE QUESTIONNAIRE
Sample Cover Letter
[COMPANY LETTERHEAD (Prime or subcontractor)]
Reference Name and Address:
Contact information:
Date:
SUBJECT: RFP-CMS- 75FCMC26R0022– ClaimsCore
Dear _________________:
We are currently responding to the Centers for Medicare & Medicaid Services (CMS) Request for Proposal number RFP-CMS-75FCMC26R0022– ClaimsCore (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 B2-21-14 Baltimore, Maryland 21244-1850
Office of Acquisition and Grants Management
SUBJECT: Solicitation RFP-CMS-75FCMC26R0022– ClaimsCore Questionnaire
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 the following agency goals: Customer Service, Financial Management, Operational Excellence, and Innovations and Technology. 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 in one of the following manners:
Email PDF (Preferred): Candace.Straker@cms.hhs.gov Lauren.Holsey@cms.hhs.gov
| Mail Original: | Centers for Medicare & Medicaid Services | |
| Office of Acquisition and Grants Management | ||
| Division of Data Center Contracts (DDCC) | ||
| ATTN: Candace Straker, Contracting Officer | ||
| 7500 Security Blvd., Mailstop B2-21-14 | ||
| Baltimore, MD 21244-1850 |
Thank you for taking the time to complete the questionnaire.
Sincerely,
| Candace Straker |
| Contracting Officer |
PAST PERFORMANCE QUESTIONNAIRE
CMS Solicitation No. RFP-CMS-75FCMC26R0022– ClaimsCore
(Company Being Evaluated) (Offeror)
Offeror/Contractor: ___________________________
| Address: | ___________________________ | |
| ___________________________ |
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:
| N/A |
| Not Applicable: Question does not apply to the contract discussed in this report |
| 0 |
| Unsatisfactory: Performance does not meet most contractual requirements and recovery is not likely in a timely manner. The contractual performance of the element or sub-element contains a serious problem(s) for which the contractor’s corrective actions appear or were ineffective. |
| 1 |
| Marginal: Performance does not meet some contractual requirements. The contractual performance of the element or sub-element being assessed reflects a serious problem for which the contractor has not yet identified corrective actions. The contractor’s proposed actions appear only marginally effective or were not fully implemented. |
| 2 |
| Satisfactory: Performance meets contractual requirements. The contractual performance of the element or sub-element contains some minor problems for which corrective actions taken by the contractor appear or were satisfactory. |
| 3 |
| Very Good: Performance meets contractual requirements and exceeds some to the Government/Business Entity’s benefit. The contractual performance of the element or sub-element being assessed was accomplished with some minor problems for which corrective actions taken by the contractor was effective. |
| 4 |
| Exceptional: Performance meets contractual requirements and exceeds many to the Government/Business Entity’s benefit. The contractual performance of the element or sub-element being assessed was accomplished with few minor problems for which corrective actions taken by the contractor was highly effective. |
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.
| Comments: |
| Rating: |
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.
| Comments: |
| Rating: |
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.
| Comments: |
| Rating: |
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.
| Comments: |
| Rating: |
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.
| Comments: |
| Yes/No: |
Agency/Company COMPLETING Questionnaire
Agency/Company Name: ___________________________
Address: ___________________________
| Signature of Individual Completing the Questionnaire: | ___________________________________ |
| Date: | ___________________________ |
Name: ___________________________
Telephone No.: ________________________
Title: ___________________________
Email Address: ________________________
Source Selection Information – See FAR 2.101 and 3.104 Page | 2 image1.png
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