World Trade Center Health Program - Comprehensive Cost Avoidance, Coordination of Benefits, and Recovery Program

Active

Contract Opportunity

The Centers for Disease Control and Prevention (CDC) Office of Acquisitions Services is issuing this Sources Sought / Request for Information (RFI) on behalf of the National Institute of Occupational Safety and Health (NIOSH) World Trade Center Health Program (WTCHP) for a potential acquisition of services to provide a Comprehensive Cost Avoidance, Coordination of Benefits, and Recovery Program

DISCLAIMER: This notice is issued solely for market research and planning purposes. It is not a Request for Proposal (RFP), solicitation, or commitment by the U.S. Government to pursue a contract. Responses are voluntary and do not constitute offers. The Government will not reimburse any costs incurred in responding to this notice. Information received will be used only for market research, and nothing in this announcement obligates the Government to take further action.

PROGRAM BACKGROUND:

On January 2, 2011, the President signed into law the James Zadroga 9/11 Health and Compensation Act of 2010 (Zadroga Act). The Act established within the Department of Health and Human Services a program to be known as the World Trade Center (WTC) Health Program. The WTC Health Program provides medical monitoring, screening, and treatment for responders and survivors of the 9/11 terrorist attacks. The statute authorizing these services directs the WTC Health Program to recover monies from workers’ compensation (WC) insurers for medical treatment (including pharmaceuticals) when the responder or survivor who is treated by WTC Health Program is also eligible for workers’ compensation benefits. The New York State (NYS) Workers’ Compensation Board (WCB) has established a Health Insurance Matching Program (HIMP) that permits health plans, such as the WTC Health Program, to identify individuals who are eligible for workers’ compensation benefits and to seek reimbursement from workers’ compensation insurers for treatment-related costs paid by the health plan.

MARKET RESEARCH OBJECTIVE:

The WTCHP seeks to identify sources capable of improving operational efficiency and controlling healthcare costs, without compromising quality of care, through the establishment of a comprehensive cost avoidance, coordination of benefits, and recovery program that spans pre- to post-payment processes.

The WTCHP anticipates a requirement for a contractor to design, implement, and operate a comprehensive, off-site program that will:

• Deploy a robust, near real-time primary insurance identification system and database;


• Validate and facilitate coordination of benefits (COB) among Program stakeholders;


• Recover incorrectly or inappropriately paid claims from Other Health Insurance (OHI) and through participation in the New York State (NYS) Workers’ Compensation Board (WCB) Health Insurance Matching Program (HIMP);


• Identify deceased members through cross-matching and verification processes; and


• Provide performance metrics, quality assurance, and payment integrity services, including fraud, waste, and abuse (FWA) detection and prevention activities.

Primary Objectives:

The anticipated requirement will focus on achieving the following five objectives:

1. Identify and maintain records of primary health insurance coverage.


2. Validate and facilitate COB activities.


3. Recoup improperly paid claims from OHI and NYS WCB insurers through HIMP.


4. Identify deceased members through reliable data sources.


5. Deliver quality assurance and payment integrity services to ensure fiscal accountability.

The contractor will be responsible for establishing and managing a comprehensive, off-site program that identifies, verifies, and communicates OHI information on a regular basis; recovers improperly paid claims; participates in the NYS WCB HIMP process; and identifies deceased members. In addition, the contractor will implement and maintain payment integrity and quality assurance functions, including clinical claims review and a fraud, waste, and abuse analytics platform, to ensure accuracy, compliance, and transparency across all financial recovery activities.

APPLICABLE NORTH AMERICAN INDUSTRY CLASSIFICATION SYSTEM (NAICS):

Potential NAICS:

524298 – All Other Insurance Related Activities

524291 – Claims Adjusting

524292 – Pharmacy Benefit Management and Other Third-Party Administration of Insurance and Pension Funds

CONTEMPLATED TYPE OF CONTRACT: A Firm-Fixed-Price (FFP) -type contract is contemplated for all services.

PLACE OF PERFORMANCE: Contractor Facility

ANTICIPATED PERIOD OF PERFORMANCE:

Base Period: July 29, 2026, to July 28, 2027

Option Period One: July 29, 2027, to July 28, 2028

Option Period Two: July 29, 2028, to July 28, 2029

Option Period Three: July 29, 2029, to July 28, 2030

Option Period Four: July 29, 2030, to July 28, 2031

SUBMISSION DETAILS:

Large and small businesses are invited to respond to this notice.

The Government requests that interested parties submit a capability statement addressing your company’s capability and experience to meet the potential requirements as described in the draft Performance Work Statement included with this notice. Please also address the market research questions identified below. The Government will assess market information to ascertain potential market capacity to: 1) Provide services consistent in scope and scale with those described in this notice, the Performance Work Statement and otherwise anticipated; 2) Secure and apply the full range of corporate financial, human capital, and technical resources required to successfully perform similar requirements; and 3) Implement a successful project management plan that includes: compliance with program schedules; cost containment; meeting and tracking performance; hiring and retention of key personnel and risk mitigation.

Please provide a capability statement AND address ALL questions below:

1) Name and address of company, with Commercial and Government Entity (CAGE) Code and Data Universal Numbering System (DUNS) number. Any interested company must be registered with Central Contractor Registration (CCR).

2) Company Point of Contact Name, Department, phone number, and email address.

3) Address whether your company is a small business under the potential applicable NAICS codes, including small business type(s)/certification(s) applicable to the NAICS code of this announcement.

4) Describe potential teaming or subcontracting opportunities for small business participation in the anticipated requirement. What percentage of work would be subcontracted?

5) Describe your organization’s capability and experience supporting federal health care programs with coordination of benefits, cost avoidance, and recovery activities similar to the tasks outlined in the Performance Work Statement, to include, identifying primary health insurance for complex health requirements.

6) Describe your organization’s capability and experience to program management and stakeholder coordination in multi-contractor environments (e.g., coordination with Third Party Administrator (TPA), Health Program Support (HPS), NYS WCB, and Clinical Centers of Excellence).

7) Describe your organization’s capability and experience for implementing a primary insurance identification system that meets the “near-real-time” (25-second) requirement and batch turnaround times.

8) Describe your organization’s capability and experience with identifying Other Health Insurance (OHI) in the absence of Social Security Numbers (SSNs).

9) Describe your organization’s capability and experience in performing electronic matching with NYS Workers’ Compensation Board’s Health Insurance Matching Program (HIMP).

10) Describe your organization’s capability and experience in ensuring timely reconciliation and accuracy (95% standard) in data matching and claim recovery processes.

11) Describe your organization’s capability and experience to identify deceased members through cross-matching with the Death Master File (DMF) and other data sources without SSNs.

12) Based on your review of the draft Performance Work Statement, what contract type would best support this requirement?

13) Are there commercially available solutions or tools that can meet the requirements of the Performance Work Statement?

14) What implementation timelines would you recommend for a program of this scale?

15) What are the key risks or challenges you foresee in meeting the performance standards outlined in the Performance Work Statement?

16) Are there industry best practices or innovative models for cost avoidance and benefit coordination that the Government should consider?

Submissions shall not exceed 15 pages.

Your response to this Sources Sought/RFI shall be electronically submitted in either Microsoft Word or Portable Document Format (PDF), via email to the Contracting Officer, Serina Allingham, at xog9@cdc.gov no later than 3:00p.m. Eastern Standard Time on Wednesday, December 21, 2025.

Please reference this Sources Sought/RFI posting in the e-mail subject line. Information and materials submitted in response to this request will not be returned. Do not submit classified material, personally identifiable information or personal health information. All data received in response to this Sources Sought/RFI that is marked or designated as corporate or proprietary will be fully protected from any release outside the Government. Since this is a sources sought announcement, no feedback or evaluations will be provided to the respondents.

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