Attachment J.3 PastPerformanceQuestionnaire.docx

PAST PERFORMANCE QUESTIONNAIRE

Sample Cover Letter

[COMPANY LETTERHEAD (Prime or subcontractor)]

Reference Name and Address Date

SUBJECT: RFP-CMS-2011-0010– Correct Coding Initiative

Dear _________________:

We are currently responding to the Centers for Medicare and Medicaid Services (CMS) Request for Proposal number RFP-CMS-2011-0010 (as a subcontractor to______ (If applicable)). The purpose of this contract is to maintain and further expand correct coding edits to ensure proper coding for part B and hospital outpatient services, enable the Center for Medicaid, CHIP, and Survey & Certification (CMCS) and the States in meeting the requirements of section 6507 of the Patient Protection and Affordable Care Act (PPACA).

There is an increased emphasis on past performance in the federal source selection process. 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, 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

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. Please be advised that neither your name, nor position or organization, will be divulged before, during or after this survey has been completed.

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 in one of the following manners:

Email PDF (Preferred): Nicole.Hoey@cms.hhs.gov E-mail is the preferred method.

Fax Original: (410) 786-9643, ATTN: Nicole Hoey, (410) 786-0489 (Please advise by phone or e-mail if questionnaire will be faxed)

Contract Specialist

Thank you for taking the time to complete the questionnaire.

Sincerely, Theresa Schultz Contracting Officer

PAST PERFORMANCE QUESTIONNAIRE

CMS Solicitation No. RFP-CMS-2011-0010– Correct Coding Initiative

Company Being Evaluated (Offeror)

Offeror/Contractor: ___________________________

Address: ___________________________

What type of Product(s)/service(s) was/are provided by the Offeror?

What type of contract(s) (Firm Fixed Price, Cost Reimbursement, Time and Material, etc.), quantity, and subtotal dollar value of each type of contract(s) do/did you have with the Offeror?

If a Government contract, what is/was the contract number?

Was the contract/subcontract(s) solicited competitively or noncompetitively?

Total value of the contract/subcontract(s) with the Offeror?

Period of Performance of the contract/subcontract(s)?

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 for Q1-Q5. 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.

Q5. Is/was the contractor committed to customer satisfaction and would you hire this contractor again?

Yes/No:

Agency/Company COMPLETING Questionnaire

Agency/Company Name: ___________________________

Address: ___________________________

Name: ___________________________ Telephone No.: ________________________

Title: ___________________________ Email Address: ________________________ image1.png oleObject1.bin