ClaimsCore Combined Synopsis/Solicitation

This document, Amendment/Modification Number 0003 to Solicitation Number 75FCMC26R0022, issued by HHSCMS, modifies a federal government solicitation. The primary purpose of this amendment is to request offerors to provide a copy of any CTA (Contract Teaming Arrangement), as applicable in Phase 2, as stated in Amendment 3 - Attachment 3, ClaimsCore Instructions to Offerors. The amendment also lists the addition of 'Amendment 3 - Attachment 3 ClaimsCore Instructions to Offerors' and the removal of clause 52.217-5 RFO 'Evaluation of Options.' This modification extends the solicitation period and outlines the methods for offerors to acknowledge receipt of the amendment. The document provides contact information for Candace Straker, Contracting Officer, and Lauren Holsey, Contract Specialist.

Solicitation # 75FCMC26R0022, "ClaimsCore Instructions," outlines a two-phase procurement process for government contractors. Phase One evaluates Corporate Experience (Mission Focused), requiring a six-page narrative detailing recent, relevant experience in areas like high-volume cloud-based claims processing, systems migrations, and financial stability. Phase Two assesses the Performance Work Statement (PWS) & Quality Assurance Surveillance Plan (QASP), Past Performance, Price, Section 508 compliance, and Business Ethics/Conflicts of Interest. Proposals must adhere to strict formatting, page limits, and submission deadlines. The government plans to make up to four awards based on a best-value tradeoff, prioritizing non-price factors. Questions are due by March 6, 2026, and Phase One proposals by March 13, 2026. The evaluation process emphasizes understanding government needs and a sound technical approach.

This solicitation (75FCMC26R0022) outlines instructions for offerors submitting proposals for the ClaimsCore project. It details a two-phase evaluation process, with Phase 1 focusing on Corporate Experience (Mission Focused) and Phase 2 on the Performance Work Statement (PWS) & Quality Assurance Surveillance Plan (QASP), Past Performance, and Price. Proposals must adhere to specific formatting, page limits, and font size requirements. Key evaluation factors include corporate experience in high-volume cloud-based claims processing, systems migrations, professional services capacity, financial stability, provider burden reduction, edit/rule conversion, and fraud detection. The document also specifies requirements for submitting questions, handling Contractor Teaming Agreements (CTAs), and addresses Section 508 compliance and business ethics/conflict of interest submissions. The Government intends to make up to four awards based on a best value tradeoff process, where non-price factors are significantly more important than price.

This amendment to Solicitation Number 75FCMC26R0022, identified as 75FCMC26R00220002, was issued on March 10, 2026, by the Division of Data Center Contracts, CMS - OAGM, located in Baltimore, MD. The primary purpose of this amendment is to correct the Phase 1 RFP submission due date as stated in Amendment 2 - Attachment 3, ClaimsCore Instructions to Offerors. It includes the addition of Attachment 11, titled "Amendment 2 - Attachment 3 ClaimsCore Instructions to Offerors," dated March 10, 2026. Additionally, the clause "52.217-5 RFO Evaluation of Options" with an effective date of November 2025, was removed from the evaluation factors for award. Offers must acknowledge this amendment to ensure their submission is considered.

Solicitation #75FCMC26R0022 outlines instructions for offerors responding to a two-phase procurement for ClaimsCore. Key requirements include digital submission formatting (Microsoft Office/Adobe Acrobat, 8.5x11” pages, single-spaced, 1” margins, 12-point font, with specific page limits for narrative sections), and attachment size limits (under 25MB). Contractor Teaming Agreements (CTAs) are permitted, but the prime offeror remains the sole contractor for payment and FPDS-NG records. Questions must be submitted via email by March 6, 2026, 11:00 AM ET. Phase One proposals, due March 13, 2026, 11:00 AM ET, require email submission to specified contacts and must include Unique Entity ID (UEI) and SAM EIN numbers. The evaluation process prioritizes non-price factors (Corporate Experience, PWS & QASP, Past Performance) over price, with up to four awards anticipated. Phase One evaluates Corporate Experience (Mission Focused), limited to six pages and covering specific focus areas like high-volume cloud-based claims processing and systems migrations. Phase Two assesses the Performance Work Statement (PWS) and Quality Assurance Surveillance Plan (QASP), Past Performance, and Price. Additionally, Section 508 compliance and Business Ethics/Conflict of Interest will be evaluated for successful offerors, though not as part of the best value determination. The PWS has a 20-page limit, and the QASP has a 5-page limit. Past Performance requires a summary of relevant contracts within the last three years, and price proposals must include a narrative Basis of Estimate and a detailed, unprotected Excel spreadsheet.

This government solicitation, #75FCMC26R0022, outlines instructions for offerors regarding the ClaimsCore procurement. It details a two-phase proposal submission and evaluation process, emphasizing that non-price factors are significantly more important than cost. Phase 1 focuses on Corporate Experience, requiring a six-page narrative demonstrating recent, relevant work in areas like high-volume cloud-based claims processing and systems migrations. Phase 2 involves the submission of a Performance Work Statement (PWS) and Quality Assurance Surveillance Plan (QASP), Past Performance information, Price, Section 508 compliance, and a Business Ethics/Conflict of Interest volume. The solicitation provides specific formatting, content, and submission guidelines, including page limits, font sizes, and electronic submission protocols. Questions are due by March 6, 2026, and Phase 1 proposals by March 13, 2026.

This amendment to solicitation 75FCMC26R0022, effective March 9, 2026, modifies a contract for Medicare claims processing software services. The purpose is to provide responses to RFP questions, issue an amended solicitation, and update several attachments including the ClaimsCore Statement of Objectives, Instructions to Offerors, and Beneficiary Quantities Claims and Unit Pricing. Key changes involve adjusting the 'True Up Clause' for specific Contract Line Item Numbers (CLINs 0004, 0006, 0008, 0010, 0012, and 0014) to allow for annual prospective price adjustments based on actual versus estimated beneficiary and claim volumes. The contractor must submit a report 90 days prior to the end of the current performance period detailing these changes and calculating estimated price adjustments for the subsequent option period. CLIN 0002 is exempt from these adjustments. Additionally, certain clauses related to service contract reporting and evaluation of options were removed, and new attachments, including a consolidated Q&A, were added.

The document outlines a series of questions and answers regarding a government Request for Proposal (RFP) for the ClaimsCore program, focusing on the Proof of Concept (PoC) phase. Key areas of inquiry include data sets and connectivity, system integration with Tier 1 systems, security and compliance requirements, performance metrics, and the migration of business logic from legacy systems. CMS clarifies that the PoC will use historical production data, will not require cross-system claims synchronization, and will involve load testing. The agency also specifies the expected format for extracted business rules, the approach to evaluating policy changes, and the responsibilities of offerors for system configuration and testing. The document addresses contractual clauses, page limitations for proposals, and the government's preference for configurable, auditable rules. It also provides insights into the timeline, deployment models, and the division of responsibilities between vendors and CMS/MAC personnel.

The ClaimsCore program by the Centers for Medicare & Medicaid Services (CMS) aims to modernize Medicare Fee-for-Service claims processing by replacing outdated legacy systems (MCS, FISS, DME, and CWF) with a flexible, interoperable Software as a Service (SaaS) Commercial-Off-The-Shelf (COTS) platform. This initiative seeks to improve beneficiary transparency, reduce provider burden, enhance fraud prevention, increase policy agility, and ensure system resilience. The program addresses challenges such as slow policy changes, limited data access, and high maintenance costs of current COBOL mainframe systems. ClaimsCore anticipates significant improvements in financial, technical, operational, and security aspects for CMS, Medicare Administrative Contractors (MACs), beneficiaries, and providers. The procurement will involve a multi-phase challenge process, including a Proof of Concept (POC) phase where vendor solutions will be tested against real CMS data to assess performance, accuracy, and operational fit before a production implementation.

This government solicitation (75FCMC26R0022 ClaimsCore Instructions) outlines instructions for offerors responding to a two-phase procurement. Key requirements include specific formatting for digital submissions (Microsoft Office/Adobe Acrobat, letter-sized pages, 1-inch margins, 12-point font), page limitations for certain sections, and guidelines for Contractor Teaming Agreements (CTAs). Questions are due by March 6, 2026, and proposals by March 1, 2026. Evaluation will use a tradeoff process, with non-price factors (Corporate Experience, PWS & QASP, Past Performance) being significantly more important than price. Phase 1 evaluates Corporate Experience, while Phase 2 assesses PWS & QASP, Past Performance, Price, Section 508 compliance, and Business Ethics/Conflicts of Interest. The government may make up to four awards and reserves the right to award without discussions.

This document outlines the instructions and evaluation criteria for Solicitation #75FCMC26R0022, "ClaimsCore Instructions." It details a two-phase proposal submission process, emphasizing formatting, page limits, and font size. Phase 1 focuses on Corporate Experience (Mission Focused), requiring a six-page narrative demonstrating recent, relevant work in areas like high-volume cloud-based claims processing and systems migrations. Phase 2 involves evaluating the Performance Work Statement (PWS) & Quality Assurance Surveillance Plan (QASP), Past Performance, Price, Section 508 compliance, and Business Ethics/Conflicts of Interest (COI). Proposals must include a detailed PWS (20-page limit) and QASP (5-page limit), an unprotected Excel spreadsheet for pricing, and past performance summaries from the last three years. Evaluation will use a tradeoff process, with non-price factors significantly more important than cost. Up to four awards are estimated. Offerors can submit questions via email by March 6, 2026, and Phase 1 proposals are due by March 1, 2026, at 11:00 a.m. ET.

Attachment 6 outlines the methodology for calculating firm-fixed prices for Medicare Claims Processing Software, subject to annual prospective price adjustments, or "True-Up." It details two pricing methodologies: Beneficiary-Based (PMPM) and Claims Volume-Based (Per Claim) pricing, applicable to specific Contract Line Item Numbers (CLINs) such as 0004, 0006, 0008, 0010, 0012, and 0014, while explicitly excluding CLIN 0002. The document establishes unit pricing assumptions, calculation formulas for annual CLIN prices, and contractor submission requirements for the annual True-Up process, which includes updated beneficiary counts, projected volumes, and recalculated prices. The Centers for Medicare & Medicaid Services (CMS) will review these submissions, allowing the Contracting Officer to make unilateral, prospective price adjustments for subsequent option periods. The attachment includes tables with estimated beneficiary quantities and claims volumes for various performance periods, with unit prices to be determined.

Attachment 6 outlines the methodology for calculating firm-fixed prices for Medicare Claims Processing Software, subject to annual prospective price adjustments, or “True-Up.” It specifies estimated beneficiary quantities, claims volume, and fixed unit prices for specific Contract Line Item Numbers (CLINs 0004, 0006, 0008, 0010, 0012, 0014), while excluding CLIN 0002. Offerors can propose pricing based on either Beneficiary-Based (Per Member/Per Month – PMPM) or Claims Volume-Based (Per Claim) methodologies. Unit prices are firm-fixed monthly and apply to software services. The contractor must submit an updated attachment annually, reflecting actual beneficiary counts, revised projections, and recalculated CLIN prices using fixed unit rates. The Centers for Medicare & Medicaid Services (CMS) will review these submissions, allowing the Contracting Officer to adjust future option period prices prospectively via unilateral modification, with no retrospective adjustments.

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Solicitation #75FCMC26R0022 outlines the instructions for offerors submitting proposals for the ClaimsCore project, a two-phase procurement by the Centers for Medicare & Medicaid Services (CMS). Proposals must adhere to strict formatting, font, and page limits, with digital submissions viewable in Microsoft Office or Adobe Acrobat. Questions are due by March 6, 2026, and Phase One proposals by March 13, 2026, both submitted via email to specified contacts. The evaluation uses a best-value tradeoff process, with non-price factors (Corporate Experience, PWS & QASP, Past Performance) being significantly more important than price. Up to four awards are estimated. Phase One focuses on Corporate Experience, while Phase Two evaluates the Performance Work Statement (PWS) & Quality Assurance Surveillance Plan (QASP), Past Performance, and Price, along with Section 508 compliance and Conflict of Interest. Offerors are encouraged to provide their best terms upfront, as awards may be made without discussions.

RFP-CMS-75FCMC26R0022, Attachment J-4, is a Past Performance Questionnaire for the Centers for Medicare & Medicaid Services (CMS) ClaimsCore solicitation. This document outlines the process for evaluating offerors' past performance, emphasizing its importance in federal source selection. Offerors identify references, who then complete and return the questionnaire to CMS. The questionnaire covers agency goals: Customer Service, Financial Management, Operational Excellence, and Innovations and Technology, each with specific questions and a rating scale (Unsatisfactory to Exceptional). Respondents must justify ratings with comments. The document includes a sample cover letter for offerors and instructions for references on submitting the completed questionnaire via email or mail to CMS Contracting Officer Candace Straker. It also details the information required from the company being evaluated and the agency completing the questionnaire.

FAR 52.212-5 outlines the mandatory and conditionally applicable contract clauses for commercial product and service acquisitions, integrating various federal laws and Executive orders. Section (a) lists seven clauses, including prohibitions on certain confidentiality agreements, Kaspersky Lab products, specific telecommunications equipment, and inverted domestic corporations, along with requirements for accelerated payments to small business subcontractors and protest procedures. Section (b) details additional clauses that the Contracting Officer has marked as applicable, covering areas such as restrictions on subcontractor sales, business ethics, whistleblower protections, executive compensation reporting, and prohibitions on ByteDance applications. It also includes clauses related to small business utilization, equal opportunity for veterans and individuals with disabilities, combating human trafficking, and Buy American requirements. Section (d) mandates Comptroller General examination of records for certain contracts. Finally, Section (e) specifies which of these FAR clauses must be flowed down to subcontracts for commercial products and services, ensuring compliance throughout the supply chain. This regulation ensures federal contractors adhere to a wide range of social, economic, and security policies.

Attachment 6 outlines the True-Up mechanism for adjusting prices of Medicare Claims Processing Software based on beneficiary quantities and unit pricing. This attachment specifically applies to CLINs 0004, 0006, 0008, 0010, 0012, and 0014, with CLIN 0002 explicitly excluded. The unit prices are firm-fixed monthly prices per unique beneficiary (PMPM) for software services. The annual CLIN price is calculated by multiplying the estimated average monthly beneficiaries by the unit price and 12 months. Contractors must submit an updated Attachment 6 annually, 90 days before the period of performance ends, detailing actual and projected beneficiary counts, and recalculated CLIN prices. The Centers for Medicare & Medicaid Services (CMS) will review this submission, and the Contracting Officer may unilaterally adjust applicable CLIN prices for subsequent option periods prospectively, with no retrospective adjustments.

This government solicitation, 75FCMC26R0022, is an RFP for a ClaimsCore program for the Centers for Medicare & Medicaid Services (CMS). The program aims to replatform Medicare Fee-for-Service (FFS) claims adjudication by replacing legacy COBOL systems with a Commercial-Off-The-Shelf (COTS) platform. The contract is a Firm Fixed Price type with an initial Proof of Concept phase and multiple option years for software and services, extending through November 2033. Key requirements include sub-second adjudication, real-time fraud prevention, and interoperability. The document details contract administration, payment procedures via the Invoice Processing Platform (IPP), and special requirements such as an annual “True-Up Clause” for software costs based on beneficiary quantities. It also outlines stringent information security, accessibility (Section 508), and HIPAA compliance, including requirements for an Information System Security Plan and a prohibition on performing work outside the U.S. without prior approval.

The ClaimsCore program by the Centers for Medicare & Medicaid Services (CMS) aims to modernize Medicare Fee-for-Service (FFS) claims processing by replacing outdated legacy systems (MCS, FISS, DME, and CWF) with a flexible, interoperable Software-as-a-Service (SaaS) platform. This initiative seeks to improve beneficiary experience, reduce provider burden, enhance fraud prevention, and increase policy agility. The program will be implemented through a multi-phase challenge process, starting with a Proof of Concept (POC) to test vendor solutions against real CMS data and established metrics for accuracy, throughput, and interoperability. The successful vendor will then proceed with a phased production implementation, integrating with existing financial and external systems while maintaining uninterrupted Medicare FFS operations. Key requirements include robust security, data rights for CMS, interoperability, and comprehensive professional services for configuration, integration, and training.