SMRC RFI.docx

RFI-CMS-SMRC-2026-001 | Centers for Medicare & Medicaid Services Request for Information – Fixed Price Pricing for SMRC Statement of Work

REQUEST FOR INFORMATION (RFI)

Fixed Price Pricing Recommendations for Supplemental Medical Review Contractor (SMRC) Statement of Work

Issuing Office: Centers for Medicare & Medicaid Services (CMS)

RFI Number: RFI-CMS-SMRC-2026-001

Issue Date: April 9, 2026

Response Due Date: April 16, 2026, 5:00 PM Eastern Time

Points of Contact:

Tracy Amos Contract Specialist Tracy.Amos1@cms.hhs.gov

Nicole Hoey Contracting Officer Nicole.hoey@cms.hhs.gov

DISCLAIMER: This Request for Information (RFI) is issued solely for information and planning purposes. It does not constitute a solicitation and shall not be construed as a commitment by the Government to issue a solicitation or ultimately award a contract. Responses to this RFI are not offers and cannot be accepted by the Government to form a binding contract. The Government will not pay for information provided in response to this RFI.

1. BACKGROUND AND PURPOSE

The Centers for Medicare & Medicaid Services (CMS) is conducting market research to gather information from qualified contractors regarding the feasibility of, and recommended approaches to, fixed-price pricing structures for the Supplemental Medical Review Contractor (SMRC) Statement of Work (SOW).

CMS is seeking input from industry to inform acquisition planning and determine whether a fixed-price contract vehicle—or a hybrid pricing structure—would be appropriate, achievable, and advantageous for the Government and contractors performing the scope of work described herein.

The SMRC SOW encompasses a broad range of medical review, program integrity, data analysis, reporting, and administrative support activities on behalf of CMS. The work includes, but is not limited to:

Medical record review and claim adjudication Discussion and Education (D&E) sessions with providers/suppliers Statistical extrapolation of overpayments ALJ hearing support and participation Monthly and annual reporting Website development and maintenance Quality control and performance monitoring IT systems setup and ongoing maintenance Record management and work tracking

2. SCOPE OF WORK SUMMARY

The following is a high-level summary of the key task areas for which CMS is seeking fixed-price recommendations. Respondents should provide pricing input for each task area individually, as well as any recommended bundled or hybrid pricing approaches.

Task 1: Medical Review for Improper Payments Conduct medical record reviews to identify improper Medicare payments. Includes claim selection, ADR letter issuance, medical record receipt and review, determination issuance, and re-review workload. Carryover costs (labor hours for original claim review, D&E sessions, and re-review workload) shall be tracked separately.

Task 2: Medical Review for Program Integrity Ad hoc medical record review projects directed by CMS for program integrity purposes. Includes project kickoff meetings, claim review, and reporting.

Task 3: Discussion and Education (D&E) Sessions Conduct educational outreach with providers/suppliers regarding medical review findings and Medicare coverage policies.

Task 4: Reporting and Performance Metrics Prepare and submit Monthly Status Reports (MSR) by the 15th of each month, including:

Total medical reviews requested and completed by project title Reviews completed by state and provider/supplier number Reviews not completed within established time standards Performance metrics, challenges, and proposed actions Tracking reports in Microsoft Excel format Task 5: Annual Performance Assessment (APA) Support Support CMS in conducting the Annual Performance Assessment, including site visits and evaluation of:

Medical Review Process Flow and Response Time Data Collection, Integration, and Reporting Medical Reviewer Credentials and Training Quality Control (Interrater Reliability – IRR) Provider/Supplier Communication Task 6: Quality Control Plan (QCP) Develop and maintain a Quality Control Plan within 14 days of award, including QA procedures, personnel responsibilities, frequency of QA functions, and policy dissemination processes.

Task 7: IT Systems Setup and Maintenance Develop and maintain IT Systems Project Plan, including:

Hardware, software, and telecommunications identification CMS system access and security clearance Weekly data backup capability Joint Operation Agreements (JOAs) and Data Use Agreements Task 8: Start-Up / Ramp-Up Activities Develop and execute a Start-Up Project Plan within 10 days of kick-off, operationalizing all SOW tasks within 90 calendar days of contract award.

Task 9: Record Management and Work Tracking Dashboard Develop and maintain a dashboard tracking:

Work days on hand by project Claims selected, reviewed, and re-reviewed ADR letters sent and records received Overpayment recoupment tracking Statistical extrapolation and data analysis activities Task 10: Website Development and Ongoing Maintenance Develop and maintain a CMS-approved public-facing website including project descriptions, ADR letter examples, hot topics, and D&E period information.

Task 11: ALJ Hearing Support Actively participate in Administrative Law Judge (ALJ) hearings (minimum 10 per month), including:

Reviewing Notices of Hearing (NOH) Preparing case documentation Assigning physicians for party/participant/witness roles Coordinating with AdQIC and other CMS contractors Optional Task 1: Fraud Referral Support Support CMS in referring potential fraud cases to appropriate investigative bodies.

Optional Task 2: Public Portal Development Develop and maintain a public-facing portal as directed by CMS.

Optional Task 3: Ad-Hoc Innovation Projects Perform ad hoc innovation projects as directed by CMS.

Optional Task 4: Statistical Extrapolation of Overpayment Conduct statistical extrapolation analyses, including methodology development, sampling, and reporting.

Optional Task 5: Recalculation of Statistical Extrapolation Perform recalculations of prior statistical extrapolations, including rationale documentation and revised reporting.

3. RFI ASSUMPTIONS:

Throughout a contract year (12-month period), the Contractor is required to follow tasks outlined in the SMRC Statement of Work (SOW) and assume the following for preparation of a response to this RFI. CMS notes that assumptions below may be revised at any point throughout the contract year based on changes to CMS priorities:

1. The Contractor shall furnish the Information Technology (IT) environment and any equipment required by its personnel to complete the medical review project/tasks and reports.

1. CMS anticipates up to 150-225 calls daily from providers/suppliers in reference to ongoing projects. In addition, the Contractor shall manage a public mailbox and anticipate responding to approximately 75 emails or more per day.

1. Print mailings may occur weekly at approximately 40 to 80 providers per mailings, to be paid by the Contractor. The Contractor shall anticipate sending secured data to 20 Medicare Administrative Contractors (MACs) and CMS monthly.

1. A valid CMS ID is required to access OnePI and use its business intelligence tools. Users must complete training in OnePI tools to access data through OnePI. The Contractor will need to provide a list of staff who will be using OnePI with details on previous OnePI training and current use of OnePI, as well as a determination on who will need the training. OnePI training classes are held monthly.

1. The Contractor shall follow IOM 100-08 Program Integrity Manual (PIM) and any revisions to the language in IOM 100-08 at http://www.cms.gov/manuals.

1. The Contractor shall maintain a public website that contains the SMRC medical review project activities and other work stream data.

1. The Contractor shall anticipate performing research and data analysis for 90% of the medical review projects assigned. It is expected that the medical claims review workload volume will remain constant. CMS anticipates that re-reviews will account for about 30% of the workload claim volumes.

The Contractor shall anticipate the following workload for each non-optional work stream:

The SMRC Provider Compliance Group (PCG) ‘Specialty Reviews’ (SOW Tasks 1, 4-11) -- Throughout the contract year, the Contractor shall expect 32,500 claims for medical record review under Medicare Part A to be dispersed between approximately 2-3 projects. In addition, the Contractor shall expect 117,000 claims under Medicare Part B to be dispersed between approximately 15-18 projects.

PCG’s Specialty Review Task (Task 1) projects can range from 2,000 to 3,000 providers or more, with no more than 40 claims sampled per provider. We note that the above number of projects may also include non-medical record review as well as research projects. For purposes of this RFI, assume that 90% of the re-reviews claim volume results in Discussion and Education (D&E) sessions with the provider/supplier.

The SMRC Program Integrity ‘Specialty Reviews’ (SOW Tasks 2, 4-11) -- Throughout the contract year, (12 months), the Contractor shall expect the following:

· 35,000 claims for medical record review under Medicare Part A, dispersed between 25-30 projects.

· 5,000 claims for medical record review under Medicare Part B, dispersed between 2-3 projects.

The current Statement of Work also includes 5 Optional Tasks which are elective and may be exercised at the discretion of CMS if a bona fide need exists during the contract year.

4. INFORMATION REQUESTED

CMS requests that respondents provide the following information:

4.1 Contractor Information

Company name, address, and DUNS/UEI number Point of contact (name, title, phone, email) Business size and socioeconomic status (e.g., small business, large business, 8(a), WOSB, SDVOSB) Relevant experience performing similar medical review or program integrity contracts All contracting vehicles which you have that this work could be procured on. (GSA, IDIQs, etc.)

4.2 Fixed-Price Feasibility Assessment

Please address the following questions:

Feasibility: In your professional assessment, is a Firm Fixed Price (FFP) contract type appropriate for the SMRC SOW? Please explain your rationale.

Hybrid Approach: Would you recommend a hybrid pricing structure (e.g., fixed price for certain tasks and cost-reimbursement or time-and-materials for others)? If so, which tasks lend themselves to fixed pricing and which do not, and why?

Risk Allocation: What risks do you foresee with a fixed-price structure for this type of work, and how would you propose to mitigate those risks?

Volume Variability: Given that the number of claims reviewed and ALJ hearings may vary month to month, how would you recommend structuring pricing to account for volume variability (e.g., unit pricing, tiered pricing, not-to-exceed ceilings)?

4.3 Proposed Pricing Structure

Please provide your recommended pricing approach for each task area listed in Section 2, including:

3.4 Staffing and Labor Categories

Provide recommended labor categories and associated fixed hourly rates (if applicable) for key personnel, including Medical Directors, Medical Reviewers, IT Staff, Project Managers, and Administrative Staff.

Describe your approach to staffing transitions between contract phases.

3.5 Performance Standards and Incentives

Would you recommend any performance incentives or disincentives tied to fixed-price task orders?

How would you propose handling performance metrics such as review accuracy, response time compliance, and reporting timeliness within a fixed-price framework?

3.6 Carryover Costs

How would you recommend handling carryover costs (work continuing beyond the one-year contract timeframe) under a fixed-price structure?

Please describe your proposed methodology for tracking and reporting carryover costs separately, as required by the SOW.

3.7 Section 508 Compliance Costs

Please describe how Section 508 compliance costs (for all deliverables, web content, and communications materials) would be incorporated into your fixed-price proposal.

3.8 Additional Recommendations

Please provide any additional recommendations, industry best practices, or innovative pricing approaches that CMS should consider for this acquisition.

4. RESPONSE FORMAT AND SUBMISSION INSTRUCTIONS

4.1 Format

Responses shall be submitted in Microsoft Word (.docx) or Adobe PDF format.

Page limit: 20 pages maximum (excluding cover page, table of contents, and attachments).

Font: Times New Roman or Arial, 12-point, with 1-inch margins.

4.2 Submission

Responses shall be submitted electronically to the CO and CS Points of Contact identified on the cover page of this RFI.

Subject line: "RFI-CMS-SMRC-2026-001 – [Company Name] Response" Responses are due no later than April 16, 2026, 5:00 PM Eastern Time.

Late responses may not be considered.

5. TERMS AND CONDITIONS

All information submitted in response to this RFI is voluntary.

Proprietary information, if any, should be clearly marked. CMS will endeavor to protect such information to the extent permitted by law.

This RFI does not commit CMS to issue a solicitation, make an award, or pay any costs associated with preparing a response.

Respondents are advised that CMS is under no obligation to acknowledge receipt of the information received or provide feedback to respondents with respect to any information submitted.

Participation in this RFI does not preclude participation in any future solicitation.

6. REFERENCES

Respondents are encouraged to review the following references prior to submitting their response:

SMRC Statement of Work (SOW) – J.1_SOW_OP7_CLEAN (007) CMS Program Integrity Manual (PIM), Publication 100-08 42 CFR §§ 405.1000–405.1058 (ALJ Hearing Procedures) Section 508 of the Rehabilitation Act of 1973 (29 U.S.C. 794d) 36 CFR Part 1194 (Section 508 Standards)

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