Request for Information for the Supplemental Medical Review Contractor (SMRC) Amendment 0001

Statement of Work (SOW) / Performance Work Statement (PWS)

This Statement of Work (SOW) outlines the requirements for a Supplemental Medical Review Contractor (SMRC) to perform medical reviews and related activities for the Centers for Medicare & Medicaid Services (CMS). The primary goal is to lower improper payment rates and increase the efficiency of medical review functions, primarily for Medicare Fee-for-Service (FFS) claims.

The SMRC will support three main initiatives within CMS's Center for Program Integrity (CPI):

• Task 1: Provider Compliance Group (PCG) Specialty Reviews: Addressing issues identified by federal agencies (OIG, GAO) and supporting CMS data analysis programs (CERT, FATHOM, PEPPER).
• Task 2: Program Integrity Reviews: Conducting medical reviews to support program integrity efforts.

The SMRC will perform nationwide medical reviews on Medicare FFS claims for Part A, Part B, and DMEPOS programs. This may involve reviewing up to 300,000 claims per project. Reviews will assess compliance with Medicare's coding, coverage, billing, and payment requirements, with recommendations for recoupment or adjustment of improperly paid claims.

Key tasks include:

• Medical Record Review (including requesting documentation via ADRs)
• Non-Medical Record Review (e.g., for non-response to ADRs)
• Research and Data Analysis
• Claim Re-review
• Maintaining a Public Website
• Record Management and Work Tracking via a dashboard system
• Customer Support
• Defending Medical Review Decisions at Administrative Law Judge (ALJ) Hearings
• Specific reviews related to the Consolidated Appropriations Act of 2023 (CAA) Telehealth study.

Optional tasks may be exercised at CMS's discretion, including Special Projects (Home Health, Third Party Liability), Public Portal development, Ad-hoc Innovation Projects, and Medi-Medi Specialty Projects.

• Medical record review decisions to be made within 30 calendar days of receiving documentation.

• Timeliness requirements for initial project reports, final project reports, and other deliverables are specified.

• Contractor must maintain IT system security controls and comply with relevant regulations (HIPAA, FISMA, FedRAMP).

• Collaboration with various internal and external entities (State Agencies, OIG, GAO, UPIC, MACs, etc.) is required.

• Use of Electronic Submission of Medical Documentation (esMD) is required.

• Performance is expected nationwide, covering all fifty states and six territories.

• Strict adherence to IT and security requirements, including obtaining an Authority to Operate (ATO) within 60 days of award.

• Personnel must be trained on security procedures, Privacy Act, HIPAA, and Freedom of Information Act.

• Development and maintenance of Standard Operating Procedures (SOPs) for key tasks.

• Key personnel requirements are defined, including Project Manager, Medical Director, and Medical Review Manager.

• Contractor must provide a toll-free customer service number and dedicated electronic mailbox.

Amendment / Modification

This amendment (0001) to the Request for Information (RFI) provides updated information and clarifies aspects of the original RFI concerning fixed-price pricing recommendations for the Supplemental Medical Review Contractor (SMRC) Statement of Work (SOW).

• RFI Number: Updated to RFI-CMS-SMRC-2026-001 Amendment 0001.
• Issue Date: Updated to April 9, 2026.
• Response Due Date: Updated to April 23, 2026, 5:00 PM Eastern Time.
• Points of Contact: Updated contact information for Tracy Amos and Nicole Hoey.
• Section 2 (Scope of Work Summary): References the attached SOW.
• Section 3 (RFI Assumptions): Provides detailed assumptions regarding contractor responsibilities for IT environment, call volume, mailings, data security, OnePI access and training, adherence to the Program Integrity Manual (PIM), website maintenance, research and data analysis percentages, and specific workload volumes for Medicare Part A and Part B claims review under both the Provider Compliance Group (PCG) and Program Integrity 'Specialty Reviews'. It also notes the existence of 5 optional tasks.
• Section 4 (Information Requested): Outlines specific information required from respondents, including contractor details, a feasibility assessment of fixed-price contracts, recommendations for hybrid pricing structures, risk allocation, handling volume variability, proposed pricing structures, staffing, performance standards, carryover costs, Section 508 compliance costs, and additional recommendations.
• Section 4.1 (Response Format and Submission Instructions): Specifies response format (Word or PDF), page limits (20 pages), font requirements, electronic submission method, subject line format, and the final due date.
• References: Lists the SMRC Statement of Work (SOW) – Amendment 0001 as a key reference.

The Response Due Date has been extended to April 23, 2026, 5:00 PM Eastern Time. Bidders should ensure their responses address all updated assumptions and information provided in this amendment.

Statement of Work (SOW)

This Statement of Work (SOW) outlines the requirements for a Supplemental Medical Review Contractor (SMRC) to perform medical reviews and related activities for the Centers for Medicare & Medicaid Services (CMS). The primary goal is to reduce improper payment rates and increase the efficiency of medical review functions, primarily for Medicare Fee-for-Service (FFS) claims.

The SMRC will support three main initiatives within CMS's Center for Program Integrity (CPI):

• Task 1: Provider Compliance Group (PCG) Specialty Reviews: Addressing issues identified by federal agencies (OIG, GAO) and CMS internal data analysis programs (CERT, FATHOM, PEPPER).
• Task 2: Program Integrity Reviews: Supporting program integrity efforts through medical reviews.

The SMRC will conduct large-volume nationwide medical reviews on Medicare FFS claims (Parts A, B, and DMEPOS), assessing compliance with coding, coverage, billing, and payment requirements. Reviews may involve up to 300,000 claims per project. The SOW also details numerous other tasks, including non-medical record reviews, research, data analysis, claim re-reviews, public website maintenance, record management, customer support, defending decisions at ALJ hearings, and a telehealth project under the Consolidated Appropriations Act (CAA).

• Timely completion of medical reviews and submission of reports as per specified timeframes (e.g., 30-day decision for Task 1, 60-day decision for Task 2).
• Adherence to IT and security requirements, including obtaining Authority to Operate (ATO) within 60 days of award.
• Maintenance of confidentiality of medical records.
• Regular reporting, including monthly status reports and final project reports.
• Quality assurance processes to ensure accuracy and inter-reviewer reliability.

Performance is expected nationwide, covering all fifty states and six territories. The SOW does not specify a fixed period of performance but outlines requirements for transition-in and close-out activities.

• Collaboration: Must coordinate with various entities including State Agencies, investigative agencies (OIG, FBI), other CMS contractors (UPIC, MACs), and professional organizations.
• IT & Security: Strict adherence to CMS IT security requirements, including Business Partner System Security Manual (BPSSM) and CMS Information Security (IS) Acceptable Risk Safeguards (ARS).
• Data Use Agreements (DUA): Contractors requiring access to Protected Health Information (PHI) and/or Personally Identifiable Information (PII) must execute DUAs.
• Personnel: Key personnel include Project Manager, Assistant Project Manager, Medical Director, Medical Review Manager, Senior Statistician, and Customer Service Manager, each with specific experience and education requirements. All personnel must meet Medicare program standards.
• Reporting: Comprehensive reporting requirements are detailed for each task, including initial project reports, final project reports, monthly status reports, and specific deliverables for tasks like research and data analysis.

Request for Information (RFI)

This RFI is issued by the Centers for Medicare & Medicaid Services (CMS) for market research purposes. CMS is seeking industry input on the feasibility and recommended approaches for implementing fixed-price pricing structures for the Supplemental Medical Review Contractor (SMRC) Statement of Work (SOW). The goal is to inform acquisition planning and determine if a fixed-price or hybrid pricing model would be advantageous for the SMRC SOW.

The SMRC SOW involves a broad range of activities including:

• Medical record review and claim adjudication for improper payments and program integrity.
• Discussion and Education (D&E) sessions with providers.
• Reporting and performance metrics.
• Annual Performance Assessment (APA) support.
• Quality Control Plan (QCP) development and maintenance.
• IT systems setup and maintenance.
• Start-up/ramp-up activities.
• Record management and work tracking dashboard.
• Website development and maintenance.
• Administrative Law Judge (ALJ) hearing support. Optional tasks include fraud referral support, public portal development, innovation projects, and statistical extrapolation of overpayments.

CMS requests information on:

• Contractor Information: Company details, POC, business size, and relevant experience.

• Fixed-Price Feasibility Assessment: Assessment of Firm Fixed Price (FFP) appropriateness, recommendations for hybrid approaches, risk allocation, and strategies for volume variability.

• Proposed Pricing Structure: Recommended pricing for each task area, staffing, labor categories, performance standards, carryover costs, and Section 508 compliance costs.

• Additional Recommendations: Any other relevant best practices or innovative pricing approaches.

• Issue Date: April 9, 2026

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

• This RFI is for information and planning purposes only and does not constitute a solicitation.

• No payment will be made for information provided in response to this RFI.

• Responses should be submitted electronically in Microsoft Word (.docx) or Adobe PDF format, with a maximum of 20 pages.