Sources Sought Notice Supplemental Medical Review Contractor.pdf

Sources Sought Notice

Supplemental Medical Review Contractor

“SMRC”

June 10, 2026

INTRODUCTION

The purpose of this SOURCES SOUGHT NOTICE (SSN) issued by the Centers for Medicare & Medicaid Services (CMS) is to determine the availability and capability of potential small businesses (e.g., 8(a), service-disabled veteran-owned and veteran owned small business, HUBZone small business, small disadvantaged business, and women owned small business) that can provide specific fee-for-service (FFS) medical review and related services, including Medicare claims appeals support services, for the “traditional” Medicare program (also known as the Medicare Fee-for-Service, or FFS program) in accordance with the Statement of Work (SOW) provided with this Sources Sought Notice as attachments.

This includes Part A, Part B, and durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) programs.

While our intention is to specifically identify small businesses, all types of business concerns, both large and small, are encouraged to submit responses to this Sources Sought Notice. The information obtained through this market research will assist the Centers for Medicare & Medicaid Services (CMS) in determining the appropriate acquisition procedures for obtaining the Medicare health insurance benefit services described in the attached SOW. This market research will aid CMS in its determination as to whether a full and open competitive acquisition is appropriate, or if the acquisition should be set aside for small businesses or a specific socioeconomic category of small businesses such as 8(a), service-disabled veteran-owned small business, HUBZone small business, or women-owned small business.

BACKGROUND AND PURPOSE OF FUTURE ACQUISITION

The CMS plans to procure a Supplemental Medical Review Contractor (SMRC) (the “Contractor”) to perform and/or provide support for a variety of nationwide, post payment medical review and related tasks aimed at lowering the improper payment rates and combatting fraud, waste and abuse. The contract consists of two separate tasks within the Center for Program Integrity (CPI):

1. The Provider Compliance Group (PCG)‘Specialty Reviews’ in support of issues identified by Federal agencies, such as the Office of Inspector General (OIG), the Government Accountability Office (GAO), etc., as well as CMS’ internal data analysis programs

2. The Program Integrity Reviews shall provide comprehensive medical review in support of CMS requests. This could include provider/supplier specific Medical Review or medical review to validate patterns identified in data.

The medical review and related tasks include but are not limited to, performing research and data analysis to identify a claim sample, preparing a medical review strategy, training internal staff, requesting medical records, performing post payment medical and/or coding review, applying coverage, coding and billing policies, educating providers and suppliers on claim review findings through Discussion and Education sessions (D&E), extrapolation of overpayments and recalculation of extrapolated overpayments, providing appeals support including defending medical review decisions at Administrative Law Judge (ALJ) Hearings. Call center support, record management and work tracking as well as the establishment of a public website and provider portal are also required. Document imaging, attachment and printing services are also necessary.

The contractor is expected to perform large volume, nationwide, post payment medical review (up to ~500,000 claims annually) dispersed between ~80-100 projects annually. Projects can also include research without medical review. The workload is dynamic. Accordingly, the Contractor must have the capability to respond quickly and efficiently to changes in workload.

RESPONSE INFORMATION

Responses to this Source Sought Notice shall demonstrate the capability to perform the specific functions provided in the list below. Responses based upon anticipated teaming arrangements and Joint Ventures are acceptable. The capability of each team member (prime contractor and subcontractors) shall be demonstrated relative to the anticipated functions/roles to be performed by each.

Give enough detail so that your response clearly indicates knowledge, experience, and capability with contract SOW requirements and the following functions:

1. Potential Offerors must demonstrate extensive knowledge and experience with operating a similar healthcare-related medical review operation and successfully integrating and managing all of the components outlined in this Source Sought Notice. The response will reflect your capabilities and experience with bringing together each of the individual elements requested in this Source Sought Notice into a single program of similar size, complexity and scope.

2. Potential Offerors must demonstrate the experience and capability with performing high volumes of post payment medical review for Medicare FFS claims across Parts A, B and DMEPOS.

3. Potential Offerors must demonstrate the experience and capability to perform program integrity medical reviews to identify fraud, waste and abuse.

4. Potential Offerors must demonstrate experience and capability to acquire and/or adjust staffing in response to frequent changes in workload without sacrificing quality and efficiency.

5. Potential Offerors must demonstrate experience and capability in performing data analysis to identify a claims sample. Potential Offerors must demonstrate experience and capability with performing claim scrubbing activities such as removing duplicate claims, claims that are under review by another Contractor, claims from an alternate Medicare payment system, providers and suppliers subject to review by a Unified Program Integrity Contractor (UPIC) or law enforcement agency, etc.

6. Potential Offerors must demonstrate extensive experience and knowledge of the Medicare program and related coverage, coding, and billing criteria.

7. Potential Offerors must demonstrate the experience and capability to handle high volume document management functions including intake, imaging, scanning, attachment, printing etc. Potential Offerors must demonstrate the experience and capability with sending, receiving and tracking large volume requests for medical record documentation.

8. Potential Offerors must demonstrate knowledge and capability with analyzing and utilizing claims data from a variety of Medicare claims systems such as the Common Working File (CWF), CMS shared systems, Recovery Auditor Contractor (RAC) data warehouse, Unified Case Management System (UCM), Integrated Data Repository (IDR), One PI (One Program Integrity), the Medicare

Appeals System (MAS), Provider Enrollment Chain and Ownership System (PECOS), National Plan and Provider Enumeration System (NPPES), etc.

9. Potential Offerors must demonstrate knowledge, experience and capability in performing large scale extrapolation and recalculation of extrapolated overpayments.

10. Potential Offerors must demonstrate the experience and capability to provide appeals support including defending medical review determinations at the ALJ level.

11. Potential Offerors must demonstrate the experience and capability to conduct a variety of Medicare provider and supplier outreach and response services such as responding to provider/supplier telephone inquiries, calling providers/suppliers to follow up on requests for documentation, providing status reports on ongoing projects/audits, etc.

12. Potential Offerors must demonstrate experience with and have the capability to obtain and/or maintain an Authority to Operate (ATO) from CMS and have policies, procedures, and practices for fulfilling Department of Health and Human Services (HHS) and CMS information security requirements.

13. CMS may create additional Information Technology (IT) systems in the future to support the ongoing development of the Medicare FFS program. Accordingly, potential Offerors must demonstrate the experience and capability required to develop processes and/or interfaces with such additional CMS systems to perform their duties.

14. Potential Offerors must have the capability of developing a provider portal specific for this contract.

Offerors may utilize a Commercial Off the Shelf (COTS) product or leverage an existing system. If the Offeror is proposing to leverage an existing system, please explain in detail how it will be distinct and separate for this contract in keeping with firewall and conflicts of interest. CMS is open to having all capabilities operationalized in phased approaches. The Offeror shall explain in detail timeframes required to have the portal up and functioning to the provider community, including details if phased approaches are being utilized. This portal must have the capabilities as outlined in the Statement of Work and meet all HIPAA and information security requirements as required by CMS and HHS.

15. Potential Offerors must demonstrate the knowledge and experience working with the Electronic Submission of Medical Documentation (eSMD) system including conducting medical reviews and/or investigations involving Electronic Health Records (EHR).

16. Potential Offerors must demonstrate capability to coordinate activities with CMS and a broad range of other agencies at the Federal, state and local levels of government as well as the capability to coordinate with other CMS partners, contractors, and a diverse range of health care stakeholders within the United States.

17. Potential Offerors must demonstrate experience and capability in using artificial intelligence to assist with non-medical review related contract tasks as outlined in the SOW.

18. Potential Offerors must demonstrate knowledge and expertise in recognizing patient harm/safety/quality issues found in medical record reviews and making referrals to appropriate areas.

19. Potential Offerors must possess superior writing skills to effectively communicate and the capability to produce in-depth reports for each medical review project performed.

WORKLOAD VOLUMES

Task 1 PCG Specialty Reviews

For Task 1, assume:

• Receiving documentation on a minimum of 110,00 claims from a mix of Medicare FFS Parts A, B and DMEPOS claims annually

• The performance of medical and/or coding review on a minimum of 110,000 Medicare FFS claims dispersed between ~10-15 projects annually

• Conducting D&E sessions for provider/suppliers for a minimum of 40,000 claims annually

• Optional task reviews could include but not be limited to an additional ~400,000 claim reviews in an option period

• Responding to a minimum of 100 monthly documentation requests to support Medicare

Administrative Contractor (MAC) appeals annually

• Attending ~20 ALJ appeals per month

• Responding to a minimum of 300 calls per day in the call center

• Responding to a minimum of 100 emails per day from the provider/supplier community

• Sending a minimum of 30,000 annual mailings to the provider/supplier community

Task 2 Program Integrity Reviews

For Task 2, assume:

• Receiving documentation for a mix of ~50,000 Medicare FFS Parts A, B and DMEPOS claims annually

• The performance of medical and/or coding review on ~ 50,000 Medicare FFS claims dispersed between 45-50 projects annually.

• Responding to ~400 monthly documentation requests to support Medicare Administrative Contractor (MAC) appeals

• Attending 30 ALJ appeals per month

• 50 calls per day in the call center

• Sending 10,000 annual mailings

BUSINESS INFORMATION

Please provide the following with your submission:

1. DUNS

2. Company Name

3. Company Address

4. Do you have a Government approved accounting system? If so, please identify the agency that approved the system.

5. Type of Company (i.e., small business, 8(a), woman-owned, veteran-owned, etc.) as validated via the System for Award Management (SAM) at www.sam.gov.Registration via System for Award Management (www.sam.gov)is a requirement for qualifying as a prime contractor with CMS. Furthermore, the small business size standard for the North American Industry Classification System (NAICS) Code 524114, Direct Health and Medical Insurance Carriers will be applicable.

6. Company Point of Contact, Phone, and Email address

7. Do have a General Services Administration (GSA) Multiple Award Schedule (MAS), if so please provide the number.

TEAMING ARRANGEMENTS

All teaming arrangements should include the above-cited information and certifications for each entity on the proposed team. Teaming arrangements are encouraged.

RESPONSE DUE DATE

Responses must be submitted electronically not later than 12:00 PM Eastern Standard Time, June 23, 2026. Submit responses to the Contracting Officer and Contract Specialist per the contact information below. Capability statements will not be returned and will not be accepted after the due date. The maximum number of pages for submission is 10 pages.

This Sources Sought Notice is for information and planning purposes only and is not to be construed as a commitment by the Government. This Notice is not a pre-solicitation notice, solicitation, or request for proposals; no contract will be awarded from this Notice. No reimbursement will be made for any costs associated with providing information in response to this Notice. Respondents will not be notified of the results of CMS’s review of any submission. No unsolicited communications regarding this SSN or requirement will be accepted. CMS WILL NOT ENTERTAIN QUESTIONS REGARDING THIS MARKET

RESEARCH.

Contracting Officer:

Nicole Hoey Centers for Medicare & Medicaid Services Email: Nicole.Hoey@cms.hhs.gov Office: 410-786-0489

Contract Specialist:

Tracy Amos Centers for Medicare & Medicaid Services Email: Tracy.Amos@cms.hhs.gov Office: 410-786-6715

ATTACHMENTS

Attachment 1: Draft SMRC Statement of Work mailto:Nicole.Hoey@cms.hhs.gov