CMS launches effort to unify Medicare claims processing systems

The Centers for Medicare and Medicaid Services has opened the window for proposals from industry in pursuit of a potential eight-year contract to provide a new software system for processing and adjudicating Medicare claims.

CMS is specifically asking for a commercial-off-the-shelf resource that can bring together the responsibilities of four other systems into a single environment for managing the claims.

Flexibility and interoperability are cornerstone features of the future ClaimsCore system, which should support more than 2 million active users and process more than 100,00 claims per day.

CMS is using a challenge-based methodology for the competition with initial bids seeking selection to participate due by 11 a.m. Eastern time on March 13, the agency said in a Friday notice to release the final solicitation. No ceiling value for the contract was provided in that document.

The agency will select up to four participants that will compete over three phases, during which bidders will demonstrate and experiment with prototype solutions that run in parallel with CMS’ existing shared systems.

Bidders will have to demonstrate that their platforms can adjudicate Part A, Part B and Durable Medical Equipment claims in near real-time, deliver outputs consistent with legacy results, and provide transparent explanations for any variances.

CMS will down-select vendors through each phase, eventually ending up with one winner that will be responsible for production and implementation.

That vendor will complete installation, integrate with all relevant external systems and process CMS claims data.

No timeline for phase two of the evaluation was given in the final request for proposals, but CMS has indicated it wants to move quickly on the effort. The final RFP points to the contract’s initial base period as ending on Jan. 1, 2027.