Request for Information (RFI) Durable Medical Equipment (DME) Claims Processing System

Background
The Centers for Medicare & Medicaid Services (CMS), part of the Department of Health and Human Services (HHS), is responsible for administering the Medicare program, which provides health insurance to senior citizens aged 65 or older and individuals with disabilities.

This Request for Information (RFI) is issued solely for CMS' information and planning purposes regarding the Durable Medical Equipment (DME) Prosthetics, Orthotics, and Supplies (DMEPOS) claims processing system. The goal of this RFI is to gather information on maintenance, developmental enhancements, modernization efforts, and special projects required by CMS.

Work Details
The DME claims processing system must meet CMS’ minimum core requirements for processing DMEPOS claims, which include:

- data collection and validation
- claims control
- pricing
- adjudication
- correspondence
- online inquiry
- file maintenance
- report generation
- reimbursement
- financial processing.

The base system consists of approximately 2,500 source modules and roughly 2,300 copy members. It is primarily written in Common Business Oriented Language (COBOL) LE with additional components in Assembler Language Code (ALC). The system includes approximately 2,800 programs made up of over 2.0 million lines of code based on traditional CICS online (COBOL) as well as COBOL and ALC batch programs. Claims are input and corrected online with features for validity checks and eligibility edits.