T1619 - Medical Consulting: External Quality Review Organization, DMAHS

Island Peer Review Organization Inc. (IPRO) has been awarded a four-year contract by the New Jersey Department of the Treasury, Division of Purchase and Property, to serve as the External Quality Review Organization (EQRO) for the Division of Medical Assistance and Health Services (DMAHS). The contract, identified as RFP/PSBE/PDVOB 24-PROS1-109783, will focus on comprehensive quality assurance activities for Managed Care Organizations (MCOs) providing healthcare services to NJ FamilyCare/Medicaid beneficiaries. IPRO will conduct annual assessments across three primary program segments: Core Medicaid, Managed Long Term Services and Supports (MLTSS), and Fully Integrated Dual Eligible Special Needs Plans (FIDE SNP).

The contract's key deliverables include performance measure validation, calculation, and quality reviews for five MCOs: Aetna Better Health of NJ, Amerigroup of NJ, Horizon NJ Health, United Healthcare Community Plan, and Fidelis Care. Specific services will encompass performance measure development, Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys, network adequacy validation, encounter data validation, and individual case reviews. The contract is effective from August 1, 2025, through July 31, 2029, with potential extensions up to two additional years. While the exact contract value was not specified in the provided documentation, the contract represents a critical quality assurance mechanism for New Jersey's Medicaid managed care programs, which as of December 2021, covered over 2 million beneficiaries.