13-RFP-25-06803 Clinical Review Services.pdf

Request for Proposal Rev. 01-13-2026

Request for Proposal #25-06803

Clinical Review Services

10801 6th Street Rancho Cucamonga, CA 91730

This RFP and any ensuing Addenda are available at the following link:

http://iehp.bonfirehub.com

NOTE: BIDDERS ARE RESPONSIBLE TO READ ALL INFORMATION THAT IS STATED IN THIS

REQUEST FOR PROPOSAL AND PROVIDE A RESPONSE AS REQUIRED

http://iehp.bonfirehub.com/

Timeline

1. The following timeline is based on IEHP’s requirements and will be strictly adhered to unless modified by written addendum:

Date: Description:

4/15/26 RFP release date 5/1/26 Bidder Questions Due (5:00 p.m. PT) 5/27/26 Bidder’s Proposals Due (2:00 p.m. PT)

2. The period of performance anticipated for this RFP shall be for an initial term of one

(1) year. At the end of the initial term, IEHP shall have the option to renew the Agreement for up to 4 additional one (1) year period(s), upon written notice. This RFP does not commit IEHP to award a contract, and there is no obligation by IEHP to purchase any specified amount of goods or services. IEHP will award a contract, if any, in its best interest and based on a proposal that best meets its needs as set forth herein.

3. IEHP reserves the right to award to multiple Bidders, based on IEHP’s needs, at IEHP’s sole discretion. IEHP reserves the right to award contracts resulting from this Request for Proposal (RFP) in whole or in part and to make multiple awards if deemed in the best interest of IEHP. The Award may be issued to multiple vendors based on the evaluation criteria set forth in this RFP, and services may be allocated among awarded vendors as determined by IEHP. IEHP further reserves the right to negotiate contract term with one or more vendors prior to finalizing any award.

TABLE OF CONTENTS

A. SOLICITATION INTRODUCTION

1. Background of IEHP

2. Key Principles

3. Primary Goals

4. Program Objectives

5. Key Selection Criteria

6. Program Outcomes

7. Target Population/Historical Information

8. Subcontracted Delegate Status

B. PROPOSAL COMPONENTS

Instructions Proposal Guidelines Bidder Acknowledgements Required Documents Required Data Company Profile Company Evaluation Criteria Scope of Services Demonstration Cost Proposal/Pricing Narrative Financial Documents Security Questionnaires Exhibit A: RFP Bidder Terms and Conditions Exhibit B: IEHP Standard Contract Terms Exhibit C: IT Security Documents

A. Solicitation Introduction

1. Background of IEHP

Inland Empire Health Plan (IEHP) is a local public entity of the State of California and is a rapidly growing Medi-Cal and IEHP DualChoice (HMO D-SNP [Dual Eligible Special Needs Plans]) health plan in California. Since September of 1996, IEHP has consistently focused on our mission: “We heal and inspire the human spirit”. As a result of the Healthcare Reform and participation in the California Coordinated Care Initiatives, IEHP grew to over 1 million members. With a provider network of over 7,500 providers and more than 3,200 employees, we now serve more than 1.5 million residents of the Riverside and San Bernardino counties who are enrolled in Medi-Cal, D-SNP, or Covered California.

IEHP’s Membership totals as of October 2025 are listed in the table below:

Line of Business Member Count Medi-Cal 1,426,230

D-SNP 38,621

Covered California 55,491 Total Membership 1,520,342

2. Key Principles

This RFP contains a list of requirements for Clinical Review Services on behalf of IEHP. IEHP’s Procurement Department is soliciting responses from qualified vendors to address the stated requirements of this RFP. A “Qualified Bidder”, for the purpose of this RFP, is one that can reliably and independently provide the required services to IEHP for the entire term of the agreement.

3. Primary Goals

The primary goals of the Clinical Review Services are to contract with a vendor who can provide board certified and California licensed physicians to conduct clinical reviews, grievance case reviews, and potential quality incident reviews. Offshore services for all lines of business are not allowed. All vendors contracted to provide services to IEHP must not utilize offshore Subcontractor(s) without a pre-approved exception.

4. Program Objectives

The primary objective of contracting with a vendor for Clinical Review Services is to ensure that IEHP meets regulatory turnaround times for physician level review of prior authorizations, grievances, and potential quality incidents (PQIs).

5. Key Selection Criteria

At the discretion of the Evaluation Team, 65 points will be allocated between the scope and company scores, 30 points will be assigned to price, and 5 points will be given for local preference. If demonstrations or interviews are conducted, an additional 10 points will be allocated to demo scores.

IEHP reserves the right, at its sole discretion, to award the contract to the responsive and responsible bidder whose proposal offers the best value to IEHP. Best value will be determined through a comprehensive evaluation of both price and non-price factors, including technical approach, experience, methodology, and other criteria specified in this RFP.

Additional details on evaluation criteria can be found in Exhibit A: RFP Bidder Terms and Conditions.

6. Program Outcomes

The outcome expectation of the successful program will support IEHP in achieving timely and compliant resolution of prior authorizations, grievances, and PQIs, in alignment with regulatory requirements and performance standards.

7. Target Population/Historical Information

Between January 1, 2025 and November 22, 2025, the current contracted vendor processed an average of 1,375 prior authorizations and 82 grievances per month. The volume for 2026 and beyond will depend on the needs of IEHP Members.

8. Subcontracted Delegate Status – YES

The services outlined in this RFP are classified as delegated administrative or healthcare services. The contractor will be recognized as a Subcontracted Delegate vendor, and must comply with all relevant requirements.

9. Piggyback Provision

Other public agencies, municipalities, and government entities within the State of California may, at their discretion and with the awarded vendor’s consent, utilize this Request for Proposal (RFP) and any resulting agreement. Any such use shall be arranged directly between the vendor and the participating entity, independent of IEHP. IEHP does not assume any responsibility or liability for contracts entered into by other entities under this provision.

B. Proposal Guidelines

Instructions:

1. This document is provided to Bidders as a reference. Bidders are not required to enter answers to Bidder questions in this document. All required questions will be found under the associated solicitation number on the Bonfire portal at http://iehp.bonfirehub.com.

a. All requested documents from each section shall be uploaded to their corresponding document slot at http://iehp.bonfirehub.com.

b. All questions from each section shall be answered by bidders in the corresponding questionnaire and/or bid table located at http://iehp.bonfirehub.com.

2. Follow the instructions in each section of this RFP.

3. All Proposals must include a detailed description of each proposed service to be provided.

4. Responses that do not comply with submission instructions may be delayed or not accepted for review.

5. Bidders that do not follow the bid instructions found in the Bidder Terms and Conditions document, attached hereto as Exhibit A, may be found to be “non-responsive” and disqualified from the bid process, at the sole discretion of IEHP.

6. A duly authorized officer of the organization must sign your RFP response.

7. IEHP reserves the right to modify or terminate the RFP process at any time. IEHP may amend or modify the project scope of services prior to the award of a contract(s), as necessity may dictate, reject any and all proposals submitted (and rebid, if necessary), accept any or all proposals submitted, negotiate with any qualified source, or cancel, in part or in its entirety, this RFP if it is in the best interest of IEHP, at IEHP’s sole discretion.

8. IEHP may keep submissions and negotiations confidential until the Governing Board approves the final contract and/or a contract is issued. Proposals may contain financial statements or other information which constitute a trade secret. In order to protect such data from disclosure, please identify the pages by clearly marking the applicable pages as confidential.

9. Upon receipt of this RFP, recipients are expected to read and understand the service priorities and requirements that have been defined by IEHP. Opportunity will be given to ask questions and receive clarification. The character and operating principles of the successful vendor are important to IEHP. The following sections ask questions about the history and purpose of the vendor’s company. Please answer the specific questions. If additional information would be informative to IEHP, please add it to the last question in each question set.

http://iehp.bonfirehub.com/ https://iehp.bonfirehub.com/

10. Each proposal will be reviewed by IEHP’s Procurement team to determine if the proposal is responsive to the submission requirements outlined in the RFP. A responsive proposal, for the purpose of this RFP, is one which follows the requirements of this RFP, includes all documentation, is submitted in the format specified in this RFP document, is submitted on time, and has the appropriate signatures required on each document. Failure to comply with these requirements may result in the proposal being deemed non-responsive and, therefore, rejected, at the sole discretion of IEHP.

11. An Evaluation Committee comprised of IEHP stakeholders will review each bidder’s responses to the questions contained in this RFP. If the respondent cannot represent and warrant the business requirements listed herein, the proposal may be rejected, at the sole discretion of IEHP.

12. The Evaluation Committee will review, evaluate, and score the proposals. The best response(s) may be recommended for another round of evaluation at IEHP’s sole discretion. IEHP reserves the right to conduct as many rounds of evaluations as it deems to be reasonable or necessary in the public interest. Each round of evaluation may result in modification of scores, further clarification or addenda being issued, and changes in the RFP process.

13. Upon evaluation of the criteria and the rating and ranking, the Evaluation Committee may choose to conduct an oral presentation/demonstration with any bidder(s). Upon completion of the oral presentations/demonstrations, the Evaluation Committee members may re-evaluate, re-score and/or re-rank the proposals remaining in consideration.

14. The price proposal will be evaluated relative to the combination of the technical proposal, including an evaluation of how well it matches the bidder’s understanding of IEHP’s needs described in this Solicitation, the bidder’s assumptions, and the value of the proposed solution and/or services. The pricing evaluation is used as part of the evaluation process to determine the bidder that will provide the best overall value to IEHP.

15. IEHP may direct negotiations with its first-choice bidder, negotiations with multiple bidders, and/or may request for best and final offers. The discussions may include price and conditions attendant to price. This RFP includes IEHP’s standard, required contract terms, attached hereto as Exhibit B, which IEHP expects to be incorporated into a final contract form together with other terms and conditions. Failure to accept IEHP’s standard terms may result in the bidder being removed from consideration.

16. Notwithstanding the foregoing, if IEHP believes IEHP and the said bidder(s) cannot reach agreement on a contract, IEHP shall exercise its right to terminate or suspend negotiations and may begin negotiations with the other bidder(s). This process may continue until a contract acceptable to IEHP has been executed or all proposals are rejected. No bidder shall have any rights against the IEHP arising from such negotiations or termination thereof.

17. A bidder’s protest of any IEHP decision to eliminate the bidder from further consideration for an award, or to award a contract to another bidder, shall be made in writing and submitted to IEHP by 5:00 p.m. PT on the fifth (5th) day following posting of Notice of Intent to Award, or posting Notice of Award of the contract, whichever occurs first. The written protest shall be submitted to procurement@iehp.org. The written protest shall fully describe each and every basis for protest and shall describe the manner in which IEHP failed to act within its discretion or abused its discretion.

For avoidance of doubt, IEHP’s intent is to reserve its discretion under this RFP to maximum amount allowed by law, and this RFP shall be construed in favor of reserving IEHP’s discretion in all circumstances. Failure to timely and completely submit a protest shall constitute a final and conclusive waiver of any and all rights to bring a legal action to challenge an award of a contract under this RFP. IEHP will not consider untimely protests or protests where the bidder failed to timely object under Section 1 of the Bidder Acknowledgements below. All bidders expressly acknowledge that IEHP may proceed with awarding and implementing a contract under this RFP while any protest, or legal action related to a protest, is pending.

mailto:procurement@iehp.org

1. Clarifications, Exceptions, or Deviations

a. All bidders must describe any exceptions or deviations from the requirements of this RFP in Question Set 1 of Questionnaire Q-67OZ. Each clarification, exception, or deviation must be clearly identified. If your firm has no clarifications, exceptions, or deviations, include a statement to that effect.

IEHP’s standard contract terms are outlined in the RFP Bidder Terms and Conditions document incorporated herein by reference, and attached as Exhibit A.

b. Any objection to the prescribed procedures, terms, conditions, or requirements set forth in this RFP or any component document must be submitted to IEHP as part of, or contemporaneously with, the bidder’s proposal. Failure to timely submit an objection, or failure to submit a proposal, constitutes a final and conclusive waiver of any and all rights to raise such objection for any purpose, including, without limitation, any protest or legal action challenging an award of a contract under this RFP.

c. All bidders must specify any additional documents that IEHP will need to sign along with the standard Agreement (e.g., appendices, requirements documents, third-party agreements, service level agreements, compliance certifications) in Question Set 1 of Questionnaire Q-67OZ. These documents must also be uploaded to the “Bidder Attachments” document slot.

d. All Bidders must specify any additional costs that IEHP will be required to pay outside of the standard agreement (e.g., third-party fees) in Question Set 1 of Questionnaire Q-67OZ. These costs should also be included in Bid Table BT-

37LS.

2. Evidence of Insurability/Business Licenses

All Bidders shall submit evidence of all required insurance in the corresponding document slot on the Bonfire website. An Acord cover page will suffice and if awarded the contract the bidder has ten (10) calendar days to produce the required insurances, including a certified endorsement naming IEHP as additionally insured.

The bidder shall certify to the possession of any and all current required licenses or certifications. Do not purchase additional insurance until this bid has been awarded.

Provide a copy of current business license or other applicable licenses. Failure to provide the required document may be grounds for disqualification of bidder from the RFP process, at IEHP's discretion.

3. IEHP General Compliance Requirements for Contractors

Bidder Acknowledgements

a. If the services provided under this RFP are designated as delegated administrative or healthcare services, the contractor will be considered a Subcontracted Delegate vendor. IEHP requires all temporary Subcontracted Delegate staff and contractors to participate in General Compliance Training as mandated by State and Federal regulations.

b. The training includes a quiz to assess knowledge of compliance topics and covers the following objectives:

• Understand the purpose and functions of a Compliance Program

• Learn the 7 Elements of an Effective Compliance Program

• Understand IEHP’s Fraud, Waste, and Abuse and HIPAA Programs, including reporting requirements and procedures for suspected non-compliance.

4. IEHP Background Check Requirements for Bidders

IEHP may require all individuals assigned to provide services under this RFP to undergo a background check prior to commencement of work, at the contractor’s expense, including any checks required by law

5. Out of Country Services Notice

a. IEHP will only consider service offerings within the continental United States, defined as the 49 States including Alaska and the District of Columbia; excluding Hawaii.

b. Proposed solutions that create, transmit, receive and/or maintain IEHP data must always reside within the United States.

c. IEHP’s data must always remain in the United States.

d. All persons, electronic processes, information systems, and devices accessing

IEHP systems or data must be physically located in the United States.

6. Executive Order N-6-22 – Russia Sanctions

On March 4, 2022, California Governor Gavin Newsom issued Executive Order N-6- 22 (the EO) regarding Economic Sanctions against Russia and Russian entities and individuals. “Economic Sanctions” refers to sanctions imposed by the U.S.

government in response to Russia’s actions in Ukraine, as well as any sanctions imposed under state law. The EO directs all California state agencies and departments to terminate contracts with, and to refrain from entering any new contracts with, individuals or entities that are determined to be a target of Economic Sanctions. All contractors and grantees are obligated to comply with the Economic Sanctions. Accordingly, should the State of California (the State) or IEHP determine

Contractor is a target of Economic Sanctions or is conducting prohibited transactions with sanctioned individuals or entities, that shall be grounds for termination of this Agreement. Contractor shall be provided with advance written notice of such termination, allowing Contractor at least thirty (30) calendar days to provide a written response. Termination shall be at the sole discretion of the State or

IEHP.

7. Registration with California Agencies

All bidders must comply with California business registration and standing requirements including:

a. Secretary of State (SOS): Register and maintain active status for your business entity (corporation, LLC, partnership) to legally operate and contract in California.

b. Franchise Tax Board (FTB): Register with the FTB, ensure good standing (i.e., no outstanding state tax liabilities), and complete any required filings to participate in public procurement.

c. IEHP Procurement Compliance: Review and adhere to IEHP’s procurement procedures as documented in the IEHP Purchasing Policies & Procedures Manual, available here: IEHP Purchasing Policy & Procedures Manual PDF

This requirement ensures bidders are authorized and fully compliant with statutory and IEHP-specific procurement rules.

https://www.iehp.org/content/dam/iehp-org/en/documents/procurement/2025/Purchasing%20Policy%20and%20Procedure%20Manual.pdf

All required documents listed below shall be uploaded to their corresponding document slot in the Requested Information section at http://iehp.bonfirehub.com.

Note: Failure to provide the required documents listed below at time of bid may be grounds for disqualification of bidder from the RFP process, at IEHP's sole discretion.

1. Principal Certification Binding Bidder’s Response (IEHP-provided form)

2. Certification of Non-Debarment (IEHP-provided form)

3. Non-Collusion Declaration (IEHP-provided form)

4. Local Preference Affidavit (If applicable – IEHP-provided form)

5. Contractor’s Certificate Regarding Workers’ Compensation (IEHP-Provided form)

6. Acknowledgment of Non-Negotiable Contract Terms (IEHP-Provided form)

7. Company W-9 Form listing company’s Tax Identification Number (TIN)

8. Evidence of Insurability (ACORD Certificate of Insurance)

9. Business License(s)

10. Proof of Registration: Documentation verifying corporate registration with the

California Secretary of State or if not a corporation, proof of tax registration with the California Franchise Tax Board.

11. Company Hierarchy/Organizational Chart

12. Credentials/Certifications/Licenses Document

13. Account Management Narrative

14. List of three (3) contracts of similar value awarded to your company in the past three

(3) years. Include the year, type of services, dollar amounts, services provided, location, contracting company, contact name, and phone number.

15. Policy and Procedures document detailing Bidder’s background checking procedures and the name of any external company utilized to perform this service.

16. Pricing Narrative

17. Redacted Pricing Narrative

18. Financial Statements

19. IEHP Security Risk Assessment

20. Data Sharing Assessment or

21. Vendor Security Documents Checklist

22. Bidder’s Security Documents

23. Credentialing Documentation of Physicians providing services to IEHP

24. Workflow of Credentialing Process

25. Annual Report for publicly traded companies, or if privately held, details of financial stability.

26. Bidder’s Standard Agreement Template, including detailed pricing and Scope of

Work (for consideration). If not available, include a detailed proposal on Bidder’s letterhead including detailed pricing and Scope of Work (for consideration).

27. References (Questionnaire Q-25PZ)

28. Cost Proposal (Bid Table BT-37LS)

29. Company Profile and Evaluation Criteria (Questionnaire Q-67OZ)

30. Bidder Response Questions (Questionnaire Q-27FT)

Required Documents

All required data listed below shall be answered in the Requested Information section at

Note: Failure to provide the required data listed below at time of bid may be grounds for disqualification of bidder from the RFP process, at IEHP's sole discretion.

1. Ownership and Campaign Contributions

IEHP is a public agency with a Board of Directors composed of elected officials and public members. Under applicable law, elected officials are restricted from voting on any action concerning a contract if the contractor’s owners have made campaign contributions of $250 or more within the previous 12 months. To assist in compliance, please provide:

a. The names of all company owners

b. Disclosure of any campaign contributions made to IEHP Board members or elected officials within the past 12 months

2. Exclusions from State and Federal Programs

a. In accordance with 42 C.F.R. §§ 438.610, 422.503 (b)(4)(vi)(F), 423.504 (b)(4)(vi)(F) and California Welfare and Institutions Code sections 14043.6 and 14123, IEHP is prohibited from employing, contracting, or issuing payments to an individual or entity that is excluded, ineligible, or terminated from participation in State and Federal health care programs.

b. Contract awards are contingent upon the bidder, its principals’ and subcontractors’, eligibility to participate in State and Federal health care programs.

c. Bidders must certify that it or any of its subcontractors do not appear on State and Federal exclusionary lists in the Requested Data section of their response on the Bonfire portal.

3. DUNS Number Provide your company’s DUNS (Data Universal Numbering System) number.

Required Data

Company Profile

This section of the proposal is designed to establish the Bidder as an entity with the ability and experience to operate the program or provide goods and/or services as specified in the RFP. The Company Profile should be concise and clear, including descriptive information regarding service delivery. All Bidders shall answer these questions in Question Set 2 of Questionnaire Q-67OZ, unless specifically stated otherwise below. Questions that also require the upload of a (Required Document) to the associated document slot are noted.

Questions that require an answer in the form of (Required Data) are also noted.

2.1 Company Name and Corporate Structure:

2.1.1 Business name and legal business status (i.e., partnership, corporation, etc.).

2.2 Company overview related to RFP services or activities performed, including:

2.2.1 Company hierarchy (President, Vice President, Company Officers, etc.) and an organizational chart. The organizational chart shall clearly identify all staff members that will provide services under this contract. Upload this document to the corresponding document slot on Bonfire. (Required Document)

2.2.2 Number of years in business under the present business name, as well as prior business names, and the number of years of experience providing the proposed, equivalent, or related services.

2.2.3 Location of the office from which the work under this contract will be provided, and the staff allocation at that office.

2.3 Provision of Services:

2.3.1 Please provide a detailed response discussing how Bidder plans on providing the services requested in this RFP; specifically, whether services will be provided by Bidder’s own forces, subcontractors.

2.4 Financial Interests:

2.4.1 Please indicate whether the Bidder holds controlling or interests in any other organization or is owned or controlled by any other person or organization. If none, please state N/A. Governmental agencies are exempt from this requirement.

2.4.2 Provide any financial interests in any other business. Individuals who are personally performing the contracted services and governmental agencies are exempt from this requirement.

2.4.3 Please indicate if the Bidder is privately or publicly held. If private, please provide details of financial stability. If public, please provide ticker symbol and copy of your most recent annual report.

2.5 Company Structure/Staffing:

2.5.1 Please describe any organizational changes (mergers, acquisitions, divestitures) that have occurred in the past five (5) years.

2.5.2 Please indicate whether Bidder has organizational changes (mergers, acquisitions, divestitures) planned within the next five (5) years.

2.5.3 Please indicate whether Bidder has any layoffs, or personnel expansions planned within the next five (5) years.

2.6 Legal:

2.6.1 Provide a detailed explanation of any litigation involving the Bidder or any principal officers thereof in connection with any contract within the last five (5) years. Is your firm, or the principals corresponding with your firm, under investigation, being sued, suing, or affiliated in any lawsuit or alternative dispute resolution with any governmental agency? If none, state N/A.

2.6.2 Has your company ever been or are you currently subject to any federal or state regulatory enforcement action including but not limited to exclusion and/or suspension from participation in a federal program?

2.6.3 List the officers of your organization who are authorized to negotiate the agreement with IEHP if awarded, and their positions within your organization.

2.6.4 Provide details of any failure or refusal to complete a contract. If none, that must be stated.

2.6.5 Has your company ever been or are you currently subject to any federal or state regulatory enforcement action including but not limited to exclusion and/or suspension from participation in a federal program?

2.6.6 State whether your company, or the principals corresponding with your company, are under investigation, being sued, suing, or affiliated in any lawsuit or alternative dispute resolution with any governmental agency. If so, please provide details.

2.7 Certification of Non-Debarment: (Required Document)

2.7.1 IEHP receives Federal and State funds. All Bidders must sign and submit the Certification of Non-Debarment document provided by IEHP in Bonfire that verifies that the bidder is not listed on any of the exclusion lists notated in the section below.

If awarded a contract, awarded vendor must notify IEHP immediately if debarred at any time during the contract period.

a. The Department of Health & Human Services (DHHS), Office of Inspector General (OIG), and List of Excluded Individuals and Entities (LEIE). Please visit https://exclusions.oig.hhs.gov.

b. General Services Administration (GSA), and the System for Award Management (SAM.gov). Please visit https://www.sam.gov.

c. California Department of Health Care Services (DHCS), and Medi-Cal Suspended and Ineligible Provider List (S&I List). Please visit https://mcweb.apps.prd.cammis.medi-cal.ca.gov/references/sandi.

d. Medicare Opt-Out List. Please visit https://data.cms.gov/tools/provider-opt-out-affidavits-look-up-tool.

2.8 Financial Stability:

2.8.1 Please detail your insurance coverage, including the name of the carrier and coverage level for General Liability.

2.8.2 Please detail your insurance coverage, including the name of the carrier and coverage level for Tech Errors & Omissions (E&O).

2.8.3 Please detail your insurance coverage, including the name of the carrier and coverage level for Cyber Crime Insurance

2.8.4 Please provide your revenue for last five (5) fiscal years.

2.8.5 Please provide your profit/(loss) for last five (5) fiscal years.

2.8.6 Please provide your company ratings (i.e., A.M. Best, Better Business Bureau, etc.).

2.9 Eligibility to Participate in Federal and State Health Care Programs (Required

Data)

2.9.1 In accordance with 42 C.F.R. 438.610, 422.503 (b)(4)(vi)(F), 423.504 (b)(4)(vi)(F) and California Welfare and Institutions Code, §§ 14043.6 and 14123, IEHP is prohibited from employing, contracting, or issuing payments to an individual or entity that is excluded, ineligible, or terminated from participation in State and Federal health care programs. Contract awards are contingent upon the bidder, its principals’ and subcontractors’, eligibility to participate in State and Federal health care programs.

Bidders must certify that it or any of its subcontractors do not appear on State and Federal exclusionary lists in the Requested Data section of their response on Bonfire.

https://exclusions.oig.hhs.gov/ https://www.sam.gov/ https://mcweb.apps.prd.cammis.medi-cal.ca.gov/references/sandi https://data.cms.gov/tools/provider-opt-out-affidavits-look-up-tool

Company Evaluation Criteria

This section of the proposal is designed to further establish the Bidder as an entity with the ability and experience to operate the program or provide goods and/or services as specified in the RFP. The Company Profile should be concise and clear, including descriptive information regarding service delivery. All Bidders shall answer these questions in Question Set 3 of Questionnaire Q-67OZ unless specifically stated otherwise below. Questions that also require the upload of a (Required Document) to the associated document slot are noted.

3.1 Differentiators

3.1.1 What do you consider to be your company’s strengths, and how do you see your company as differentiated from other Bidders?

3.1.2 Is there any other information you would like IEHP to know about your company including value-added services?

3.2. Account Management Team (Required Document)

3.2.1 In the corresponding document slot on Bonfire, please provide the name(s) and general background(s) of each member of your account management team that will be assigned to IEHP. Include the information below:

• Functional area to which each person reports

• Years of service with your organization

• Total years of experience with commercial product implementation and operations

• Number of public entity accounts currently handled

• General size of the accounts (in terms of number of employees)

3.3 Organizational Information:

3.3.1 Provide a summary of the work plan and/or methodology and physical resources (staff and equipment) your company will commit to ensure successful services are provided pursuant to this RFP.

3.3.2 Will IEHP have a dedicated team assigned throughout the implementation? If so, who? Provide the organizational structure and experience for each team member, if not outlined above.

3.3.3 Summarize your company’s billing procedures.

3.3.4 What office will support IEHP?

3.3.5 Please indicate your company’s total number of employees this year and last year.

3.4 Administration:

3.4.1 Describe any customer and/or member services available on-line.

3.4.2 Could IEHP link their website to your website?

3.4.3 Do you have a customer service department? If so, what is the phone number, and the hours of operation?

3.4.4 Please describe how your customer service department is organized. Would IEHP receive a dedicated team?

3.5 Experience:

3.5.1 Describe your company’s experience/history with providing the services requested in this RFP.

3.5.2 Describe your company’s experience with Health Maintenance Organizations.

3.5.3 Describe your company’s relationship/experience with governmental regulators (e.g., Department of Health Services, Department of Managed Healthcare, and the Centers for Medicare and Medicaid Services).

3.6.1 Credentials/Resumes/Certifications/Licenses: (Required Document)

In the corresponding document slot on Bonfire, please provide information for all employees/subcontractors responsible for administering or providing services.

Provide a summary list of the organizational personnel that will actively participate and contribute their skills to this project. Include in this list:

• Name

• Job title

• Work location and

• Responsibilities

• Qualifications/Experience

• Relevant experience in projects of similar size and complexity. (Responses may be one page per individual.)

• Education

• Certifications/licenses, if applicable

• Years of service with your organization

• Total years of experience

• List other pertinent information that will assist in evaluating Bidder’s qualifications.

3.7 Awarded Contracts: (Required Document)

3.7.1 In the corresponding document slot, provide a list of three (3) contracts of similar value awarded to your company in the past three (3) years. Include the year, type of services, dollar amounts, services provided, location, contracting company, contact name, and phone number.

Scope of Services

Summary of Services The following criteria will be required of the Awarded Vendor:

Inland Empire Health Plan (IEHP) is seeking a vendor who can provide board certified physician reviewers to support IEHP's internal Medical Directors. The vendor will assist in the timely and compliant completion of prior authorization determinations, grievance reviews, and potential quality incident evaluations that have been escalated to the Medical Director level. Vendor will review escalated grievances providing impartial clinical opinions and written rationales that align with state and federal regulations, evidence based medical guidelines, and plan policies. Vendor will assess and document potential quality incidents, provide recommendations for corrective actions, and support quality improvement initiatives as requested.

The partnership will ensure adherence to regulatory timeframes, promote consistency in clinical decision making, and enhance the plan's capacity to deliver efficient, high-quality, and member focused care.

Deliverables.

1. Clinical Review of Prior Authorizations:

a. Evaluation of medical necessity and appropriateness of requested services in alignment with IEHP's clinical guidelines and regulatory requirements.

2. Grievance Case Review:

a. Objective assessment of grievances to ensure fair and clinically sound resolutions.

3. Potential Quality Incident (PQI) Review:

a. Expert analysis of flagged cases involving potential deviations from accepted standards of care.

Regulatory, Compliance, Health Insurance Portability and Accountability Act (HIPAA) Requirements.

1. All vendor physicians must be Board Certified and hold active unrestricted medical licenses in the state of California and remain in good standing with state and federal authorities.

2. All work must comply with Medicaid, Medicare and potentially in the future Covered California program requirements, HIPAA regulations, and CMS and State mandated turnaround times.

3. All reviews must follow evidence based medical criteria.

4. Compliance with California specific privacy laws.

5. No downloading printing or storing PHI outside of the approved system or locally on physician laptops.

6. All reviews must be completed within regulatory and contractual turnaround times.

7. Complete all trainings required by the health plan, including but not limited to the initial and annual IEHP Compliance, Fraud, Waste and Abuse, and Privacy training.

8. Complete all required training on health plans policies, systems, and cultural competency standards.

9. Participate in trainings, case audits, quality review meetings, and compliance reporting processes, as requested by the health plan.

10. Must make physicians available for peer-to-peer calls as required.

11. No use of external drives.

12. Must take and pass a yearly Inter-Rater Reliability (IRR) test.

13. Vendor physicians can not be contracted to work at any IEHP in-network facilities and/or regularly see IEHP patients in their practice.

14. Vendor staff must document determinations directly within the health plan's existing electronic systems.

15. Case volume may fluctuate on a monthly basis. The vendor must demonstrate the ability to provide adequate staffing capacity to meet workload surges, while maintaining compliance with timeliness requirements. Currently the plan has a greater need for reviewers during the time period of 1pm-6pm and weekends, subject to change.

16. Staffing levels must remain within contracted parameters, with any changes subject to health plan approval.

17. Clinical rationales provided are evidence based aligned with Medicaid, Medicare and potentially at a future time Covered California, and Plan policy and demonstrate at least 95% compliance upon audit review.

18. Vendor physicians are available during agreed coverage hours and demonstrate responsiveness to urgent case escalations.

19. Stakeholder feedback (health plan staff and committees) indicates overall satisfaction with vendor performance.

Technical Requirements.

1. Physicians will be required to use MedHok and Microsoft applications (Word, Outlook, etc.).

2. Vendor physicians will need access to a laptop or computer and be able to remote into the IEHP internal network.

Timeliness.

Escalated prior authorization cases must be reviewed within regulatory timeframes, which vary by program and determination type. For Medicaid and Covered California, standard requests require a decision within 7 calendar days and urgent requests within 72 hours, though cases escalated to the Medical Director queue may have significantly shorter remaining windows depending on prior processing time. For Medicare, standard requests must be resolved within 7 calendar days and urgent requests within 2 business days. Written clinical rationales that are evidence-based, compliant with state and federal regulations, and defensible in audits or appeals.

1. Minimums after onboarding:

a. Potential Quality Incidents: 2 per hour

b. Grievances: 4 per hour

c. Prior Authorizations: 6 per hour

2. Turnaround time for Prior Authorization reviews- 100% completed within mandated timeframe, 24/48/72 hours to 7 days depending on urgency) and/or average hours/days from assignment to completed review.

3. Grievance Resolution Timeliness- 100% resolved within required regulatory deadlines and/or average hours/days from assignment to completed review.

4. Response Time to Quality Incident Reviews- Average hours/days from assignment to completed review.

5. Accuracy and Compliance.

6. Regulatory Compliance Rate - 100% of cases processed in compliance with IEHP, CMS, DHCS and DMHC requirements.

Contractor Responsibilities.

1. Credentialing of Physicians.

2. Tracking of billing hours.

3. Communication to and from employed Physicians, as needed.

4. Regular check ins with IEHP contract owners and stakeholders bi-weekly and/or monthly.

5. Accountable for financial sanctions if minimum requirements are not met.

Reporting and Monitoring.

1. Vendor will need to provide credentialing documentation/proof (as needed), tracking of hours billed by contracted Physicians, and case identifiers for any cases completed.

2. Performance will be monitored in accordance with IEHP’s Delegated Subcontractor Manual and policies (https://www.iehp.org/en/our-organization/who-we-are/compliance-program) which may include dashboards, KPIs, routine monitoring, routine audits, and focused audits through monthly or biweekly check-ins with the Contractor’s account representative to review contracted physician reviewer performance, ensure compliance with regulatory timeframes, and address operational issues such as policy updates, staffing adjustments, or invoice and payment concerns. These discussions will also serve to identify opportunities for process improvements and strengthen alignment with the health plans organizational goals.

https://www.iehp.org/en/our-organization/who-we-are/compliance-program

Bidder Response Questions (Questions in this section must be answered in Questionnaire Q-27FT, unless specifically stated otherwise)

1. Questions for Bidder Responses

[Pass / Fail]

Mandatory Requirement

1.1.1 Are all of your Physicians who are performing services under this RFP Board Certified and hold active unrestricted medical licenses in the state of California, and remain in good standing with state and federal authorities?

1.1.2 Will all of your physicians who are performing services under this RFP be physically located in the United States of America?

1.1.3 All Physicians must have at least 5 years of clinical experience as a licensed physician in a healthcare setting.

1.1.4 Physicians should have some experience working in Utilization Management (UM), including familiarity with UM processes and standards.

[Questions are scored by each Evaluator on a scale of 1-10]

Bidder Questions

1.2.1

How many licensed California physicians are available to perform services for IEHP described in this RFP? Please describe their specialties and experience working with Health Plans.

1.2.2 Are all of your physicians physically located within California, United States of America? If not, please disclose which state physicians are physically located.

1.2.3 Provide a detailed description of your credentialing process.

1.2.4 How are your physician reviewers recruited, credentialed, and re-credentialed?

1.2.5

Describe your organizations experience in performing the clinical review functions outlined in this RFP, specific to your experience with other Health Plans, and in Medi-Cal Managed Care, Medicare Advantage, and Medicare Dual Special Needs Plans.

1.2.6

a. How do you ensure your physician reviewers remain current with evidence based medical guidelines and

b. Stay current on revised/updated regulatory requirements imposed on IEHP?

Please include a description of your training processes and any ongoing education or compliance measures in place to maintain alignment with regulatory guidance.

1.2.7

Please describe what other value-added services does your organization inherently include (without additional cost to IEHP) as part of your service offerings to this RFP?

1.2.8 Is your organization willing to participate in monthly meetings to review performance metrics, address any challenges or concerns?

1.2.9 What is your standard turnaround time for prior authorization determinations, grievance reviews, and quality incident evaluations?

1.2.10 How do you ensure adherence to regulatory timeframes?

1.2.11 What corrective action or improvement processes are in place if performance issues are identified?

1.2.12 Describe your PHI data security measures.

Compliance Program Questions

2.1.1 Compliance Program Organizational Structure

Describe your Compliance Program structure, including the reporting structure of the Compliance and HIPAA Privacy Officer(s), Chief Executive Officer, Compliance Committee and Board of Directors/Governing Body.

2.1.2 Compliance, Fraud, Waste and Abuse (FWA), and HIPAA Privacy & Security Training Describe your process for developing, disseminating, and conducting Compliance, FWA, and HIPAA privacy & Security training, including population required to complete these trainings, content, development, and training management.

2.1.3 Regulatory Exclusion Screenings

Describe your organization’s exclusion screening process, including the lists reviewed, frequency, process, and actions taken in response.

2.1.4 Downstream Entities

Describe the criteria and process implemented to identify downstream entities, to manage, and to oversee these entities.

2.1.5 IEHP Subcontractor Compliance Program Requirements Manual Describe any challenges or concerns with adherence to the IEHP Subcontractor Compliance Program Manual and associated policies located on the IEHP.org website (https://www.iehp.org/en/our-organization/who-we-are/compliance-program).

Cost Proposal/Budget Narrative

In Bid Table BT-37LS, please submit pricing for the services requested in this RFP. Cost Proposals will be disclosed to the evaluators after the evaluation of the technical proposals has been completed. IEHP reserves the right to negotiate final fees with the selected Bidder(s). Proposals must fully describe all costs of charges to IEHP as part of this service/project. As stated in the Cost Proposal, Bidders must provide fully inclusive blended rates, which are all-encompassing of the Bidder’s project-related or supported expenses, including travel expenses. Bidders may also include any other documents as information to further explain the proposed costs. Any special government rates or considerations should be included in Bidder’s quotation.

Cost proposal must be all-inclusive and include, but not be limited to, administration, travel, training and related costs.

Cost Proposal:

Service Type Description Unit Cost for Each Unit of Service:

Physician Review Services (Authorization Reviews) Per Hour

Physician Review Services (Potential Quality Incident Reviews) Per Hour $

Physician Review Services (Grievance Reviews) Per Hour $

Physician Review Services (Authorization Reviews) Per Review $

Physician Review Services (Potential Quality Incident Reviews) Per Review $

Physician Review Services (Grievance Reviews) Per Review $

PRICING NARRATIVE (Upload EACH to its corresponding document slot)

1. Pricing Narrative (WITH PRICING):

In a separate document, provide a timeline with major milestones up to implementation.

Define your proposed method of reimbursement for services at each stage of this project provided through your company and elaborate on the costs provided within the Bid Table submission. IEHP customarily prefers itemized billing on a project basis (or as major milestones are accomplished for very large projects) with specific deadlines identified in the proposal.

Include a description of any additional costs that may be incurred in completion of this project and the circumstances that would trigger those costs. Please include the pricing for these additional costs in the Bid Table, not in the pricing narrative.

2. Pricing Narrative (WITH REDACTED PRICING):

Upload a copy of the above requirement with all pricing redacted.

Financial Statements (Required for Proposals over $200K)

The bidder must submit financial statements (Balance Sheet, Income Statement, and Statement of Cash Flows, or equivalent documentation to the satisfaction of IEHP) for its business that are dated no more than twelve (12) months prior to the date of the proposal submission and cover a period of at least two (2) years. These statements should clearly identify the financial status and condition of the bidder's entire business entity. Financials should provide sufficient detail to assure IEHP that the bidder can support services being offered and the contractor will not seek early payment for services delivered, expedited payments or checks delivered by any means other than regular mail through IEHP’s Accounts Payable.

The bidder must provide the following documentation, or equivalent documentation to the satisfaction of IEHP, herein referred to as Financials, of sufficient financial strength and resources to provide the scope of services as required:

1. Two (2) years of most recent audited financial statements (Balance Sheet, Income Statement, and Statement of Cash Flows, or equivalent documentation to the satisfaction of IEHP). The audited financial statements must be:

a. Prepared with all monetary amounts detailed in United States currency;

b. Prepared under United States Generally Accepted Accounting Principles; and

c. Audited under United States Generally Accepted Auditing Standards.

2. Most recent unaudited Year-To-Date financial statements (Balance Sheet, Income

Statement, and Statement of Cash Flows.

3. If the cash flows are negative for the most recent operating period, the documentation must include a detailed explanation of the factors contributing to the negative cash flows.

4. Contact Information of person to provide clarifications regarding Financials.

Due to the California Public Records Act and the Brown Act, IEHP cannot guarantee that the Financials submitted will be kept confidential. IEHP offers several solutions to our Bidders below. Bidders may submit Financials using the following methods:

1. Preferred - Upload Financials to its corresponding document slot at http://iehp.bonfirehub.com no later than 2:00 p.m. PT on or before bid close date. Or;

2. Mail in a hard copy of Financials with a stamped return envelope to the address listed on the cover page of this solicitation no later than 2:00 p.m. PT on or before bid close date. IEHP will mail back Financials using the return envelope upon completion of review.

IT Security Documents

As part of the requirements related to services that will be provided under this Request for Proposal (RFP), Bidders must complete a detailed Security Risk Assessment. This assessment is provided in the form of a spreadsheet with five distinct tabs, each covering different aspects of IT security.