J-08_PastPerformanceQuestionnaire_1_08_10.doc

CMS-RFP-2010-0016

Attachment J-08 Past Performance Questionnaire

PERFORMANCE QUESTIONNAIRE

Sample Cover Letter

[COMPANY LETTERHEAD (Prime or subcontractor)]

Reference Name and Address

Date

SUBJECT: RFP-CMS-XXXX-XXXX– DME MAC Contractor Dear _________________:

We are currently responding to the Centers for Medicare and Medicaid Services (CMS) Request for Proposal number RFP-CMS-XXXX-XXXX (as a subcontractor to______ (If applicable)). The purpose of this contract is to perform claims process activities in accordance with the Durable Medical Equipment Medicare Administrative Contract (DME MAC) requirements.

There is an increased emphasis on past performance in the federal source selection process. The Contracting Officer requests 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, Department of Health & Human Services

Centers for Medicare & Medicaid Services

7500 Security Boulevard, Mail Stop C2-21-15

Baltimore, Maryland 21244-1850 Office of Acquisition and Grants Management

SUBJECT:

Solicitation RFP-CMS-2010-0016– DME MAC Contractor, Past Performance 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. Category 0 or 1 responses will be referred to the Offeror to permit rebuttal. Please be advised that neither your name, nor position within your organization, nor this survey, will be divulged before, during or after this survey has been completed.

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):

James.Wilkerson@cms.hhs.gov E-mail is the preferred method.

Fax Original:

(410) 786-9922, ATTN: James Wilkerson, (410) 786-5586 (Please advise by phone or e-mail if questionnaire will be faxed) Mail Original:

Centers for Medicare and Medicaid Services

Office of Acquisition and Grants Management

Division of Medicare Contracts

ATTN: James Wilkerson

(410) 786-5586 Contract Specialist

7500 Security Blvd., C22115

Baltimore, MD 21244-1850

Thank you for taking the time to complete the questionnaire.

Sincerely, Jaime Galvez

Contracting Officer

PAST PERFORMANCE QUESTIONNAIRE

CMS Solicitation No. RFP-CMS-2010-0016– DME MAC Contractor Company Being Evaluated (Offeror) Offeror/Contractor:

Address:

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. Note: Use of the term “Agency” can be interpreted as also Government/non-Government agencies or customers.

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 was 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:

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Source Selection Information – See FAR 2.101 and 3.104 Page | 1

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