Supplemental Medical Review Contract

SMRC Statement of Work 1 Centers for Medicare & Medicaid Services Supplemental Medical Review Contractor (SMRC) Statement of Work (SOW) June 3, 2026 -- 1 of 82 -- SMRC Statement of Work 2 Table of Contents I. Purpose .................................................................................................................................................. 3 II. Background ...................................................................................................................................... 3 III. Requirements.................................................................................................................................... 4 A. Collaboration with Other Internal and External Entities .................................................................. 4 B. Information Technology (IT) Policies and General Requirements................................................... 4 C. Privacy Act ....................................................................................................................................... 8 D. CMS Security and Privacy Language for Information & Information Technology ......................... 8 E. CMS Data Use Agreements (DUA) ................................................................................................. 8 F. Work Functions ................................................................................................................................ 9 G. Tasks Capabilities & Requirements ............................................................................................... 11 H. Assumptions and Constraints ......................................................................................................... 13 IV. Key Personnel and Staffing ............................................................................................................ 14 V. Statement of Work Tasks ............................................................................................................... 18 Task 1: PCG Specialty Reviews .............................................................................................................. 19 Task 2: Medical Reviews for Program Integrity Support ........................................................................ 23 Task 3: Perform Non-Medical Record Review ....................................................................................... 28 Task 4: Discussion and Education (D&E) ............................................................................................... 29 Task 5: Claim(s) Re-Review ................................................................................................................... 31 Task 6: Research ..................................................................................................................................... 33 Task 7: Data Analysis.............................................................................................................................. 34 Task 8: Public Website ............................................................................................................................ 35 Task 9: Public Portal ............................................................................................................................... 35 Task 10: Customer Service Support ........................................................................................................ 36 Task 11: Defending Medical Review Decisions at Administrative Law Judge (ALJ) Hearings ............. 37 Task 12: Record Management and Work Tracking ................................................................................. 39 Task 13: Contract Ramp-Up and Contract Close-out & Transition......................................................... 43 VI. Optional Tasks................................................................................................................................ 47 Optional Task 1: Ad-Hoc Innovation Project(s) ...................................................................................... 48 Optional Task 2: Statistical Extrapolation of Overpayment or Potential Overpayment .......................... 48 Optional Task 3: Recalculation of Statistical Extrapolation of Overpayment ......................................... 49 VII. Deliverables.................................................................................................................................... 49 Appendix A: CMS Security and Privacy Language for Information and Information Technology (IT) ..... 56 Appendix B. Information Security Certification Checklist ......................................................................... 76 Appendix C. Prospective Offeror Non-Disclosure Agreement ................................................................... 77 Appendix D. Contractor Non-Disclosure Agreement.................................................................................. 78 Appendix E. References .............................................................................................................................. 79 -- 2 of 82 -- SMRC Statement of Work 3 I. Purpose The Centers for Medicare & Medicaid Services (CMS) is seeking a Supplemental Medical Review Contractor (SMRC) to perform post payment medical reviews (MR) and medical review related activities in support of initiatives within the Center for Program Integrity (CPI) to include the following: 1) The Provider Compliance Group (PCG) ‘Specialty Reviews’ for issues identified by Federal agencies, such as the Office of Inspector General (OIG)0F 1 , Government Accountability Office (GAO) , and other CMS groups. In addition to support CMS’ internal data analysis programs to include the Comprehensive Error Rate Testing (CERT)1F 2 program; the First-look Analysis Tool for Hospital Outlier Monitoring (FATHOM)2F 3 , and the Program for Evaluating Payment Patterns Electronic Reports (PEPPER)…