23CSMC-213C-RFP-FINAL-04.19.24.pdf

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RICARDO LARA

CALIFORNIA INSURANCE COMMISSIONER

REQUEST FOR PROPOSAL

Notice to Prospective Proposers

04/19/2024

You are invited to review and respond to this Request for Proposal (RFP), entitled Independent Medical Review (IMR) RFP # 23CSMC-213C. The California Department of Insurance (CDI) intends to award one (1) contract for three (3) years, with up to two (2) optional 12-month extensions. In submitting your proposal, you must comply with these instructions.

Note that all agreements entered into with the State of California will include by reference General Terms and Conditions and Contractor Certification Clauses that may be viewed and downloaded at Internet site https://www.dgs.ca.gov/OLS/Resources/Page-Content/Office-of-Legal-Services-Resources-List- Folder/Standard-Contract-Language. If you do not have Internet access, a hard copy can be provided by contacting the person listed below.

In the opinion of CDI, this RFP is complete and without need of explanation. However, if you have questions, or should you need any clarifying information, the contact person for this RFP is:

Mark Valim, Contract & Record Analyst

California Department of Insurance

Financial and Business Management Division - Business Management Bureau

BMB_Procurement@insurance.ca.gov

Please note that no verbal information given will be binding upon the State unless such information is issued in writing as an official addendum.

https://www.dgs.ca.gov/OLS/Resources/Page-Content/Office-of-Legal-Services-Resources-List-Folder/Standard-Contract-Language https://www.dgs.ca.gov/OLS/Resources/Page-Content/Office-of-Legal-Services-Resources-List-Folder/Standard-Contract-Language https://www.dgs.ca.gov/OLS/Resources/Page-Content/Office-of-Legal-Services-Resources-List-Folder/Standard-Contract-Language

California Department of Insurance (CDI)

RFP # 23CSMC-213C

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Table of Contents Section Page(s) A) Purpose and Description of Services 3-14 B) Minimum Qualifications for Proposers 14-15 C) Proposal Requirements and Information 15-24

1) Key Action Dates 15

2) Content of Proposals 16-18

3) References 18

4) Cost Proposal 18

5) Submission of Proposal 18-21

6) Evaluation Process 21-23

7) Award and Protest 23

8) Miscellaneous Award Issues 23-24

9) Disposition of Proposals 24

10) Agreement Execution and Performance 24

D) Preference Programs 24-28

1) Small Business Preference 24-26

2) DVBE Incentive 26-27

3) Target Area Contract Preference Act (TACPA) 27-28

E) Required Attachments 28-46

1) Required Attachment Check List 30

2) Proposal/Proposer Certification Sheet 31-32

3) Cost Proposal (Budget Form) 33

4) Criteria for Evaluation of Content Proposals 34-37

5) Criteria for Cost Evaluation/Summary 38

6) Bidder Declaration 30

7) Proposer References 39-40

8) Proposer Samples 41

9) Disabled Veterans Business Enterprise 42

Participation Forms and Instructions

10) Darfur Contracting Act Certification 30

11) Confidentiality and Non-Disclosure Agreement 43

12) Conflict of Interest Certification and Agreement 44

13) Non-collusion Statement 45

14) California Civil Rights Laws Attachment 30

15) Commercially Useful Function 46

16) Contractor Certification Clauses (CCC) 04/2017 30

17) Payee Data Record (STD 204) & 30

Payee Data Record Supplement (STD 205) Contractor Certification Clauses (CCC) 04/2017 30

18) Generative Artificial Intelligence (GenAI) Disclosure & Factsheet (STD 1000)

F) Definition of Terms 28 G) Start of Work 28 H) Termination 29 I) Licenses & Permits 29 J) State of California – Insurance Code 29 K) Sample Standard Agreement (STD 213) 47-61

1) Exhibit A, Scope of Work 48-56

2) Exhibit B, Budget Detail and Payment Provisions 57

3) Exhibit C, General Terms and Conditions (GTC 04/2017) 10

4) Exhibit D, Special Terms and Conditions 58-60

5) Exhibit E, Resumes 61

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A) Purpose (Background) and Description of Services

The California Department of Insurance (CDI) requests proposals in accordance with each of the terms and conditions in this Request for Proposal (RFP). The purpose of this RFP is to solicit proposals that will lead to the selection of a prime contractor to provide Independent Medical Reviews (IMR) for CDI.

The competitive bidding process being used for this procurement of services is known as the RFP Secondary Method. This method requires evaluation of proposals by an evaluation committee with the award made to the responsible proposer earning the highest score.

CDI reserves the right to not award any contracts associated with this RFP.

Proposers should carefully review the requirements of this proposal package, which includes a complete explanation of the CDI's needs which must be met, and instructions which prescribe the format of proposals as outlined in section A) Purpose (Background) and Description of Services, 2) Contract Scope of Work.

1) Objective

The CDI is seeking a firm to conduct IMRs as related to determinations of insurance companies under California Insurance Code (CIC) section 10145.3 and sections 10169-10169.5. Please see IMR CIC sections 10169 –10169.5. The number of requests will vary from month to month. Proposers should be aware that a contract award does not guarantee any minimum or maximum number of IMRs.

The estimated history of IMRs provided in the past three (3) years are as follows.

The selected Proposer shall have sufficient administrative facilities and staff, organizational policies and procedures and available qualified medical reviewers, free from conflicts of interest, to provide timely, complete and professional case analysis and determinations, as required in J) State of California - Insurance Code.

2) Contract Scope of Work (Narrative Response)

The Proposer must describe the overall approach to the work, specific techniques, strategies and quality controls that will be used, and specific administrative and operational management expertise that will be employed. proposer must show ability to meet deadlines. Proposer may include recommendations.

Proposer must demonstrate knowledge of the insurance industry, and compliance with J) State of California - Insurance Code (Page 29) , including an understanding of why, when and what Independent Medical Reviews are and how they are used for consumers.

Proposer shall provide reports and forms to demonstrate sound management of its IMR capabilities and operations.

The following is an overview of how a case eligible for an IMR will be processed:

STEP 1: An insured requests an IMR from the CDI Consumer Services and Market Conduct Branch - Health Claims Bureau (HCB) Insurers will inform the insured of the right to request an IMR when it makes a final determination on the requested health care service. The insured will submit an application via the secured online portal(s) for an IMR to the HCB.

Year 2020 2021 2022 # Requests Completed

274 192 197 https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?sectionNum=10145.3&lawCode=INS http://leginfo.legislature.ca.gov/faces/codes_displayText.xhtml?lawCode=INS&division=2.&title=&part=2.&chapter=1.&article=3.5 http://leginfo.legislature.ca.gov/faces/codes_displayText.xhtml?lawCode=INS&division=2.&title=&part=2.&chapter=1.&article=3.5

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STEP 2: The HCB accepts the case for IMR The HCB will review the application and determine its eligibility for IMR as authorized per CIC sections 10169 and 10169.1. Timeline to complete this determination will be handled on a case-by-case basis.

Depending on the medical condition of the insured, the treatment under dispute, information from treating physicians, and information from the insurer, the HCB will also determine whether the review shall be obtained on an expedited basis.

STEP 3: Information is forwarded to the Contractor/Proposer The HCB will contact the contracting IMR organization by telephone, or electronic mail and assign the IMR to the contracting IMR organization for review. The contracting IMR organization will review the IMR Application, HCB Request for Insurance Coverage Information (RICI) and HCB cover letter to obtain clarity on the services and duration of treatment that is the subject of the IMR request and contact HCB if there is any ambiguity. The HCB will notify the health insurer and the insured that the case has been accepted and assigned for an IMR. For standard reviews, the health insurer will provide the Proposer with copies of medical records and all other relevant information concerning the medical issue in dispute within three (3) days of the HCB’s notification. For expedited reviews, the insurer will provide the Proposer with copies of medical records and all other relevant information concerning the medical issue in dispute within 24 hours of the HCB’s notification.

STEP 4: The Contractor/Proposer will obtain the review The Proposer shall assign the IMR case to the appropriate type and number of qualified medical reviewers. The Proposer will obtain and review the reviewers’ findings and submit the determination in writing to the HCB, insured, insurer and the insured’s medical provider within thirty (30) days. If the Proposer requires more time to complete its review, the Proposer will provide an interim status report to the HCB, insured, insurer, and the insured’s medical provider within thirty (30) days.

STEP 5: The HCB will adopt the determinations made by the Contractor/Proposer CIC section 10169.3(f)

a) STAFFING

The Proposer shall provide a description of the staff positions involved during:

- receipt of incoming records and information

- initial case assessment and assignment

- after-hours capabilities for expedited cases

- reviewer requests for additional information

- sufficient staffing to ensure the timely submission of the proposer’s written determination

- case file organization and storage.

Available Staff The Proposer shall provide names, location, board specialties, areas of expertise and California license status of medical reviewers available to the Proposer. The Proposer shall describe the relationships (staff, independent contractor). Information on available non-physicians shall also be provided.

Credentialing The Proposer shall provide written policies and procedures used to identify, recruit, and verify professional credentials. Proposer shall describe how currency in reviewer licensing and professional requirements are monitored. Proposer shall describe the verification process of a prospective reviewer’s disciplinary and sanction record.

https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?sectionNum=10169&lawCode=INS https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?sectionNum=10169.1.&lawCode=INS https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?sectionNum=10169.3&lawCode=INS

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Orientation/Training The Proposer shall provide written policies and procedures for orientation and on-going training of administrative and reviewer personnel. The Proposer shall demonstrate its ability to recruit California-licensed medical professionals to conduct reviews.

Resumes

Proposer must provide the resumes of 1) the project manager, 2) the person signing the contract, and 3) all personnel responsible for day-to-day operations of the Agreement.

The Proposer shall describe the review and verification process of a prospective reviewer’s disciplinary and sanction record.

Proposer shall verify capability to provide the following services:

The Proposer must have appropriate staff available to perform professional and nonprofessional assignments required by the IMR program. The appropriate staff’s assignments shall include, but will not be limited to, recruiting and verifying credentials of reviewers, performing conflict of interest checks, managing the review process, drafting, reviewing and revising written determinations, and maintaining the confidentiality of medical records and other data.

The Proposer shall verify the professional qualifications of reviewers before assigning reviews.

The Proposer shall provide orientation and periodic training on the IMR process for both staff and reviewers and will administer a written quality control management program to promote timely and objective professional reviews pursuant to the contract.

The quality control management program will include standards and procedures for verifying that reviewers have appropriate levels of education, licenses, board-certification, hospital privileges and professional standing, and have no history or pending disciplinary actions or sanctions.

Suspensions, sanctions, expirations, lapses or revocations of any licenses, accreditations or certifications held by the Proposer’s professional staff or by the Proposer shall be grounds to immediately cease using the services of the individuals involved and shall be reported to the Department.

Any additional entities for which the Proposer provides review services shall be reported to the

Department within five (5) business days (entities include, but are not limited to, health care service plans, insurers licensed by the CDI, or California-based provider groups or self-funded/self-insured employee benefit plans); (review services include, but are not limited to, external medical review, utilization review, quality assurance review, technological assessments, second opinions, and terms of coverage reviews.

The Proposer shall provide consulting and research services, which will include reviews of health care treatments or clinical issues regarding health insurance that will assist the Department on matters that do not involve a particular insureds grievance. Such issues may include, but are not limited to, analysis and assessment of specific therapies, the scope of appropriate referral practices and access to specialists, and assessment of emerging issues affecting the provision of medical care. The analysis or assessment provided by the Proposer may be in the form of a White Paper or other appropriate document as determined by the Department.

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The research services shall be thoroughly described in writing by the CDI Contract Manager/Project Representative specifying the task and/or deliverable to be completed by the Proposer (see Step 3), and shall incorporate the maximum rate or amount to be paid to the Proposer for the task and/or deliverable, as agreed upon by the Department and the Proposer.

It is anticipated that the projects may include and require thorough review of relevant and current medical and industry literature and policies, reference to, or copies of resources and references used and the submission of written reports of conclusions and opinions, as required by the CDI.

b) QUALITY ASSURANCE

Proposer shall describe the in-house quality assurance program and the systems to continuously improve the organization’s operations and demonstrate a commitment to quality assurance.

Proposer shall describe the role of medical professionals in the oversight of IMR operations and processes; procedures for case handling and management; frequency of evaluation of the review processes for timeliness, completeness and clarity of reviews.

Proposer shall define the roles and responsibilities of administrative and professional staff in the monitoring of reviews and the reporting of any reviewer-specific or system issues, problems and complaints. Proposer shall describe in the proposal the communication systems used to notify and respond to problems or corrective actions.

The Proposer will have a quality assurance system to ensure the content of completed reviews meets professional and statutory requirements and to address problems or issues.

The Proposer and the CDI will confer mostly in writing and occasionally by telephone as necessary to review any complaints received about a particular IMR or to discuss issues relating to the overall IMR system. The Proposer will respond:

(1) within five (5) days of receiving any requests, including requests regarding billings, from the

CDI concerning a case reviewed during the preceding thirty (30) days or

(2) within fifteen (15) days of receiving requests concerning other matters, including any systemic issues or problems relating to the performance under the contract or pursuant to the CDI’s general oversight of the IMR system.

The Proposer and the CDI shall confer as necessary to assure consistent and effective implementation of the IMR system, including but not limited to instructions provided to reviewers, designated points of contact and the Department’s quality assurance system.

Following at least one week’s notice, or seven (7) calendar days, the Department (or a Proposer or consultant acting on behalf of the Department) may conduct an on-site quality assurance review of the Proposer’s office procedures and record systems as may be deemed necessary by the Department.

The Proposer shall have a process in which each reviewer shall be required to sign a certification on an annual basis acknowledging that they are aware of and will abide by the confidentiality and conflict-of-interest requirements as outlined in CIC Section 10169.2.

https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?sectionNum=10169.2&lawCode=INS

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c) ASSIGNMENT OF CASES

The Proposer shall describe the method of selecting the number and specialties for a particular case. Include a description of how the reviewers are assessed to be knowledgeable about a particular medical condition, proposed treatments and the guidelines and protocols in the area under review; how the availability of reviewers will be determined; and the method for obtaining a medical specialist not previously available or under contract with the Proposer (including non-physicians).

Proposer shall describe how preference shall be given to California-licensed reviewers; and how Proposer assures that prospective reviewers are assessed to ensure a fair, impartial and qualified analyses.

Proposer shall describe how expedited reviews will be initiated and completed.

Proposer shall describe processes to review medical records and other documents for relevancy, completeness and legibility prior to being forwarded to reviewers.

Proposer shall describe the tracking system: acceptance for review, information gathering, and timely determinations, and the extent to which the process demonstrates an ability to respond and act on requests from reviewers for additional or updated information on a case.

The Proposer must have written policies and procedures to allow timely and effective referral of cases to qualified reviewers. If necessary, the Proposer may confer with the HCB prior to assignment of a case.

Once the HCB accepts a case for IMR, the Proposer will be contacted in writing by electronic mail to confirm its availability to conduct the review. Within two (2) business days for a standard review or within twenty-four (24) hours for an expedited review, the Proposer shall confirm in writing by electronic mail its availability to obtain the necessary review.

The Proposer will have direct toll-free telephone access between 8:00 AM and 5:00 PM, Pacific Standard time, Monday through Friday and have the capability to receive and act upon information, if necessary, twenty-four (24) hours per day, seven (7) days per week (including holidays) if notified in writing electronic mail.

d) INFORMATION TO CONDUCT REVIEWS

The Proposer shall be responsible for obtaining all necessary information to conduct the required review.

The Proposer will receive all information from the Department, insurer, insured and treating physician, and review it for legibility, completeness, and relevance to the case, before submitting the information to the assigned reviewer(s). The Proposer will also review the IMR Application, HCB RICI and HCB Cover Letter to obtain clarity on the services and duration of treatment that is the subject of the IMR request and contact HCB if there is any ambiguity regarding the subject of the review. The Proposer will notify the Department in writing by electronic mail the next business day when written information from the insurer described in CIC section 10169 (n) has not been received within three (3) business days for a standard review or within twenty-four (24) https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?sectionNum=10169&lawCode=INS

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The Proposer shall provide information and reports, as requested by the Department, to include, but not limited to, the date medical records were received, the date the case was reviewed by the reviewer, the date of the determination, the number of days from the receipt by the Proposer of the application for review and all supporting documentation to the rendering of the determination by the Proposer in writing, and the date the insured was notified of the determination. Additional reports and information may be required by the Department. The Proposer shall also provide summaries of determinations in a format and time frame requested by the Department.

Within one (1) business day, the Proposer will contact the sender in writing by electronic mail regarding any illegible or incomplete information in order to ensure a timely and effective determination.

The Proposer, not the individual reviewer, shall contact and obtain any additional information from the insurer, insured, or any medical provider(s) or the Department that is required to make a determination in the case. Copies of requests for additional information and responses shall be provided to all interested parties within one (1) business day.

e) CHANGES IN CASE STATUS

The Proposer will notify the Department within one (1) business day in writing electronic mail when the insurer, insured or any medical provider fails to comply with requests that will delay or preclude a timely and effective assessment by the reviewers.

The Proposer will notify the Department within one (1) business day in writing by electronic mail when an assigned expert reviewer cannot submit a timely or effective determination in a case due to prohibited affiliations. The Proposer will advise the Department in writing by electronic mail as soon as possible when circumstances occur that will prevent completing the review:

within thirty (30) calendar days following receipt of medical records for standard reviews;

within seven (7) calendar days of an expedited [CIC section 10145.3(c)(2) and 10169.3(c)] experimental or investigational review; or within three (3) calendar days for other expedited reviews.

The Proposer will notify the Department within one (1) business day in writing electronic mail if, upon receipt of information from the insured, insurer, provider or assigned reviewer, any of the following changes in an assigned review are necessary:

(1) the type of health care service under dispute;

(2) the type of review needed (experimental/ investigational or medical necessity);

(3) the priority of the review (standard or expedited); or

(4) the issue(s) submitted for review is (are) no longer in dispute due to the insured’s medical condition or the insurer’s actions.

Proposer shall not be entitled to payment if the Department withdraws the IMR case prior to the receipt of medical records by the Proposer. The Proposer shall only be entitled to receive payment of a minimum fee if the Department withdraws the IMR case subsequent to receipt of the medical records.

The Department reserves the right to request a re-review of a case.

https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?sectionNum=10145.3&lawCode=INS https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?sectionNum=10169.3&lawCode=INS

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f) NUMBER AND TYPE OF REVIEWERS

Proposer shall provide a list of the types of reviews (i.e., medical necessity, expedited/standard medical reviews, and investigation/experimental reviews) the Proposer can provide and the maximum number of the types of reviews that can be provided per month.

Reviewers shall be assigned to cases based upon clinical experience, education and background, including consideration of the expertise in the same or similar specialties that perform, evaluate or treat the health care service at issue. The Proposer shall give California-licensed reviewers preference, if available and qualified.

The Department shall have the discretion to designate the number of reviewers and the professional specialties.

At least three (3) reviewers will be assigned to reviews involving experimental or investigational therapies unless the Department, at the request of the Proposer, approves a lesser number.

For medical necessity reviews, the Proposer will normally select the medical specialties and number of reviewers required to render a timely, objective and effective review.

g) CONTENT OF REVIEWS

The Proposer will ensure that reviewer (s) promptly review all pertinent medical records of the insured and other appropriate information submitted relevant to the case, and the determinations and analyses are conducted professionally, thoroughly and in a timely manner.

If more than one reviewer is assigned to a case, reviewers may, but are not required to, confer as appropriate and necessary. Each reviewer must provide an individual assessment of the case that sets forth the reviewer’s professional determination. Reviews will be written in plain English to the extent practicable, will contain a determination on whether or not the disputed health care service shall be provided, and will state the reasons supporting the analysis, specifically referencing:

the insured’s medical condition the relevant medical records and other documents reviewed and the medical and scientific evidence considered along with the relevant statutory criteria set forth in CIC section 10169.3 (b) or CIC section 10145.3 (d), as applicable, that the reviewer used to make the case decision.

Findings will also clearly state:

For disputed experimental or investigational services (CIC section 10145 reviews) – whether the medical or scientific criteria demonstrating that the proposed therapy is or is not more likely to be more beneficial for the insured than any available standard therapy, and the reviewer’s basis for that conclusion.

For reviews based on CIC section 10169 - whether the disputed health care service is medically necessary.

https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?sectionNum=10169.3&lawCode=INS https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?sectionNum=10145.3.&lawCode=INS https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?sectionNum=10145.&lawCode=INS https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?sectionNum=10169.&lawCode=INS

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For reviews of denied claims for urgent and emergency medical services as described by CIC section 10169 (j) – whether the care provided was medically necessary.

A reviewer may make a conditional determination in favor of providing the disputed care based on further, specifically-described test or examination results of the insured. The Department and the Proposer may confer and agree on other specific questions and issues to be submitted to reviewers.

h) DISTRIBUTION OF COMPLETED REVIEWS

The Proposer shall be responsible for the distribution of the completed review to the interested parties.

The Proposer will summarize the determination reached by the reviewer(s) and provide each written analysis and determination by the reviewer(s) to the Department, insurer, insured and the insured’s provider, accompanied by the detailed case summary that includes the specific standards, criteria, medical and scientific evidence, if any, which led to the case decision, the credentials and qualifications of the reviewer or reviewers, and the number of days to complete the review after receipt of all documentation shall also be submitted to the Department electronically in a Word Document or other electronic format as determined by the Department.

The names of reviewers shall be kept confidential in all outside communications, unless disclosure is required pursuant to the Department’s quality assurance activities or in response to court order.

The Proposer will complete its review and distribute the determinations and analyses as follows:

within thirty (30) calendar days following receipt of medical records for standard reviews;

within seven (7) calendar days of an expedited [CIC section 10145.3(c)(2) and 10169.3(c)] experimental or investigational review; or within three (3) calendar days for other expedited reviews.

i) CONFIDENTIALITY OF RECORDS AND INFORMATION

The Proposer will ensure that any transfer and storage of medical records and confidential information is protected against unauthorized disclosure as required by federal and state law.

Information about the diagnosis, treatment, health and personal identifying information of any insured shall be made available to reviewers and other personnel only to the extent necessary to ensure performance under the contract. The Proposer will maintain case files, including all records, correspondence, reference materials and documents pertaining to the review, for at least five (5) years, or for three (3) years after final payment under the contract, whichever is later. Also see Audit, in General Terms and Conditions for Non-IT Services (GTC 04/2017) for additional information and requirements.

No information obtained by the Proposer, its staff, its contractors or subcontractors under this contract, or from the performance hereunder, shall be used for marketing, solicitation or other commercial purpose. Any disclosure or use of information developed, received or maintained under this contract that is not directly related to the review, quality assurance or accreditation activities of the Proposer or the Department’s IMR process, requires the written consent of the https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?sectionNum=10169.&lawCode=INS https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?sectionNum=10145.3.&lawCode=INS https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?sectionNum=10169.3.&lawCode=INS https://www.dgs.ca.gov/-/media/Divisions/OLS/Resources/GTC-April-2017-FINAL.pdf

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Department.

No unauthorized person(s) shall have access to any materials furnished by the Department to Proposer.

All financial, statistical, personal, technical and other data and information relating to the Department’s operations which are designated confidential by the Department and made available to the Proposer in order to carry out this contract, or which becomes available to the Proposer in carrying out this contract, shall be protected by the Proposer from unauthorized use and disclosure.

Proposer shall not be required under the provisions of this section to keep confidential any data or information that is or becomes publicly available, is already rightfully in the Proposer’s possession, is rightfully obtained from third parties, or is independently developed by the Proposer outside the scope of this contract.

The methods and procedures employed by the Proposer for the security of the Department’s data and information may not be changed unless the Department has given its prior approval in writing.

j) LIQUIDATED DAMAGES CLAUSE

Proposer shall verify agreement with the following provisions:

The Proposer’s performance of IMR services under the contract provisions will be evaluated throughout the contract period. The Proposer will be expected to provide IMR services as stated in this contract. The Proposer’s failure to meet the requirements as stated herein will be reviewed and action taken according to the severity of each service failure. Termination may result if the Proposer s performance interferes with the Department’s operation and/or has created excessive charges to the Department.

The Proposer and State agree that such damages shall be presumed to be the damages actually sustained by the State and that because of the nature of the project, if would be impracticable or extremely difficult to fix the actual damages. Liquidated damages shall be considered not as a penalty but as agreed monetary damages sustained by the State for increased project administration expenses related to this Contract because the Proposer failed to perform and complete work within time fixed for completion or extension of time as may have been allowed pursuant to the provisions hereof.

k) REPORTS

Within fifteen (15) days of each month-end, the Proposer shall file a report of the reviews completed during the previous month and shall submit the report to the Department by electronic mail , compatible database files, or electronic mail. The report information shall include, but not be limited to the following:

Proposer Name Reporting Period IMR Case Number CDI File Number Insurer Name Insured’s Name

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Date case assigned to Proposer Date documents/records were received from the Plan Date the Proposer’s Determination was sent Number of days from the receipt by the Proposer of the application for review and all supporting documentation to the rendering of the determination by the Proposer in writing The Type of Review Undertaken: investigational/experimental services; medical necessity determinations; or reimbursement of urgent/emergency service claims.

Whether the review was performed on an expedited or standard basis.

Number of reviewers assigned, the ID number, medical specialty, and the credentials and qualifications of the reviewer or reviewers as set for in CIC section 10169.2 (d)(4)(A&B) of the California Insurance Code.

Whether the Plan’s determination was reversed or upheld by the reviewer.

Patient Information: age, sex, diagnosis, medical care/procedure in dispute.

The Proposer shall provide CDI with a final, comprehensive written report covering the entire contract period. The final comprehensive report shall provide a summary of each IMR analysis and determination. The final report shall be provided as a Word document, or other electronic format as determined by CDI, and sent by electronic mail to IMRO@insurance.ca.gov.

l) PROHIBITED AFFILIATIONS1

Proposer shall verify agreement with the following provisions:

The Proposer’s relationship with health plans, insurers, facilities and related industries in a prospective case shall be under review: the Proposer shall have information and procedures in place to readily determine whether its ownership, management, employees, professional staff and reviewers have any prohibited affiliations in a particular case that would disqualify either the Proposer or a reviewer from performing a review.

The Proposer shall not be an affiliate, subsidiary, or in any way be owned or controlled by a health plan, insurer, a trade associations of health plans or a trade association of insurance companies.

A board member, director, officer, or employee of the Proposer may not serve as a board member, director, or employee of a health care service plan or insurer. A board member, director, or officer of a health plan, insurer, trade association of health plans or trade association of insurance companies may not serve as a board member, director, officer, or employee of the Proposer.

Neither the Proposer, its designated experts conducting a review, nor any officer, director, or employee shall have any material professional, familial, or financial affiliation (for definition of these terms1) with:

The insurer or any officer, director, or employee of the insurer.

The physician, medical group, independent practice association involved in the health care service in dispute.

The facility or institution where either the proposed or recommended health care would be provided. An academic medical center under contract to the insurer to provide services to insured may qualify as a proposer provided it will not provide the service and provided the center is not the developer or manufacturer of the proposed treatment.

The development or manufacture of any drug, device, procedure, or other therapy proposed or recommended by the insured or insurer.

The insured or the insured's immediate family.

The Proposer shall submit to the Department all information delineated in CIC section 10169.2(d)(2) upon initial application to contract for the IMR program and annually thereafter upon https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?sectionNum=10169.2.&lawCode=INS mailto:IMRO@insurance.ca.gov https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?sectionNum=10169.2.&lawCode=INS

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m) INSURANCE REQUIREMENTS

Proposer shall verify capability to provide the following documentation:

The Proposer shall secure and maintain, throughout the contract period, insurance coverage as stipulated below. At a minimum, coverage shall contain the following elements:

1. Comprehensive general and professional liability insurance of not less than $1,000,000 per claim and $3,000,000 total coverage for the entire term of the contract.

Insured’s will include the Proposer and its employees, agents and reviewers, and insure against any liability, including liability for bodily injury, which may arise from or be related to arranging and performing independent reviews.

The State of California, the Department of Insurance and the officers, agents, employees and servants will be included as additional insureds with respect to work performed under the contract for independent medical reviews.

2. Workers’ Compensation insurance in accordance with the laws of the State of California and with a minimum of $500,000 Employer’s Liability, issued by an insurance carrier licensed to underwrite workers’ compensation insurance in the State of California.

The Proposer shall furnish to the Department a Certificate of Insurance evidencing that such insurance coverage is in full force and effect. The Certificate of Insurance shall provide:

a) that the insurer shall not cancel or terminate the insured’s coverage without thirty (30) days advance written notice to the contracting representative of the Department.

b) the Department shall not be responsible for any premiums or assessments on the policy.

The Certificate of Insurance shall comply with those standards as determined by the State of California, Department of General Services (DGS), Office of Insurance and Risk Management.

Certificates are subject to DGS approval and the Proposer agrees that no work or services shall be performed prior to the receipt of such approval.

In the event insurance coverage expires at any time during the term of the contract, the Proposer agrees to provide, at least thirty (30) days prior to said expiration date, a new Certificate of Insurance evidencing insurance coverage as provided herein for not less than the remainder of the term of the contract, or for a period of not less than one (1) year.

In the event Proposer fails to keep in effect at all times insurance coverage as herein provided, the Department may, in addition to any other remedies it may have, terminate this contract upon the occurrence of such event.

The Department will not provide for nor compensate Proposer for any insurance premiums or costs for any type or amount of insurance.

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3) Billing Information

a) Proposer costs related to items such as travel and per diem are costs of the proposer. CDI shall not pay for such costs as part of this contract nor as a separate item.

1 Definitions of Conflict of Interest Terms:

“Material familial affiliation” means any relationship as a spouse, child, parent, sibling, spouse’s parent, or child’s spouse.

"Material professional affiliation" means any physician-patient relationship, any partnership or employment relationship, a shareholder or similar ownership interest in a professional corporation, or any independent Proposer arrangement that constitutes a material financial affiliation with any expert or any officer or director of the independent medical review organization.

"Material professional affiliation" does not include affiliations that are limited to staff privileges at a health facility.

"Material financial affiliation" means any financial interest of more than five (5) percent of total annual revenue or total annual income of a proposer or individual. "Material financial affiliation" does not include a reviewer’s participation as a contracting plan provider where the expert is affiliated with an academic medical center or a National Cancer Institute-designated clinical cancer research center.

B) Minimum Qualifications for Proposers

1. These are minimum qualifications that Proposers must have in order to compete for this RFP (See C, Proposal Requirements & Information, C2, Content of Proposal):

a) Service and Activities: Provide evidence of being in the business of providing IMRs, standard of care assessments or similar analyses of health care decision-making. The Proposer must have been providing these services for a minimum of (5) years prior to this RFP and detail the extent of activity during those years. Provide description of the nature of the organization’s services and activities.

Note: when the business was established, brief history, and location.

b) List all offices and locations used by the prospective Proposer. Include the function, relationship, and whether the offices are franchised, wholly owned, or independently affiliated. List the location(s) of the office(s) from which the primary work on this contract would be performed. Proposer must give evidence that it has at least one (1) California office and will provide service through this location.

c) Proposer must describe any significant changes in the firm’s organization and staffing during the previous three (3) years.

d) Proposer must provide a description of any complaints regarding the (prospective proposer’s) activities or actions, filed with any court, governmental regulatory agency, or governmental or private consumer advocacy entity that is either pending or resolved, within the past three (3) years. Include a description for the actual or expected resolutions of any such complaint, and a description of any such complaints resolved through monetary compensation outside of the above formal processes.

e) Proposer shall attach licenses, certificates, accreditation to perform IMRs, utilization management or other health-related reviews, from a state or federal agency, the Institute for Medical Quality, American Accreditation Healthcare Commission/URAC, National Committee on Quality Assurance, or other such bodies.

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f) Memberships: Proposer must provide the name and address of all professional associations in which they currently hold membership(s).

C) Proposal Requirements and Information

1) Key Action Dates

Event Date Time RFP available to prospective proposers 04/19/2024 ____

Written Question Submittal Deadline 04/26/2024 5:00 PM PST (via email to BMB_Procurement@insurance.ca.gov)

Response to Written Questions/Answers* 05/03/2024 ____

Final Date for Proposal Submission 05/17/2024 4:00 PM PST (via email to BMB_Procurement@insurance.ca.gov)

Notice of Intent to Award* 06/03/2024 ____

Proposed Award Date* 06/24/2024 ____

*These dates are estimated; therefore, this RFP will not be subject to a formal addendum should they change.

mailto:BMB_Procurement@insurance.ca.gov

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2) Content of Proposal

a) Proposals should provide straightforward and concise descriptions of the proposer’s ability to satisfy the requirements of this RFP. Failure to provide all requested information or deviation from the required format may result in disqualification.

1. Proposers shall provide all examples, documents, etc. in relation to B) Minimum Qualifications for

Proposers (A-F) as stated above.

2. Certify using Attachment 2 – Proposal/Proposer Certification Sheet that the mandatory requirements are met as stated in Section B) Minimum Qualifications for Proposers.

b) Project Personnel

1. Project Manager: Identify one (1) individual on the Proposer's team who will manage the contract work (Project Manager). Document overall experience in IMR services, with a minimum of five (5) years of experience/service in this area.

2. Resumes: Proposer must provide the resumes of 1) the project manager, 2) the person signing the contract, and 3) all personnel responsible for day-to-day operations of the Agreement.

3. Organization Chart: Proposer must submit an organization chart, showing the hierarchy of key personnel working on project(s). Chart must show the relationship between project manager and key personnel of the Proposer’s organization and all other parties (including subcontractors, if any) to the proposal.

4. Subcontractors: Identify all proposed major subcontractor(s). Document which portions of service will be performed by subcontractors and the ability to perform the work. Include resumes of subcontractor(s) key personnel. Do not exceed two (2) pages per person.

The proposer must make it clear to any subcontractors included in the proposal that the use of subcontractor(s) are subject to approval by the CDI Project Representative.

c) Description of the Firm

1. Provide a description of the specializations of your firm.

2. Provide a description of safeguards that your firm employs to ensure that confidential information is safely maintained and accessed only for the purposes of providing services subject to this RFP.

d) IMR Experience

1. Provide a brief description of the experience required under the minimum qualifications in Section

B) Minimum Qualifications for Proposers.

2. Provide a brief description of the firm’s experience providing consulting services.

3. Provide a brief description of the firm’s qualifications and experience that demonstrate its capability to provide the scope of work described in Section A) Purpose (Background) and Description of Services.

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e) Scope of Work

1. The proposal must provide written explanation regarding all the items in A) Purpose (Background) and Description of Services, 2) Contract Scope of Work in detail. Must include Client References, Work Samples, Conflict of Interest issues and address the remaining required Scope of Work capabilities.

2. If awarded the contract, the Proposer agrees to provide proof of current insurance at the time of contract signature (A) Purpose (Background) and Description of Services, 2) Contract Scope of Work, Insurance Requirements).

3. Financial Statements Proposer must provide evidence of financial stability: The proposer must document sufficient financial resources necessary to perform all services associated with this contract.

i. Financial statements are required in the form of an audited balance sheet and income statement for the last two years.

ii. Financial statements must include an opinion by a Certified Public Accountant (CPA) that the statements fairly represent the financial condition of the proposer organization, that the financial statements have been prepared in accordance with Generally Accepted Accounting Principles, and that they have been audited by a CPA.

iii. Any audit exception must be fully explained. A disclaimer of the opinion will not satisfy the requirements of this section.

4. Financial Disclosure

i. If publicly held, Proposer must provide the names of all stockholders and owners of more than five (5) percent of any stock or options.

ii. Proposer must provide the names of all holders of bonds or notes in excess of $100,000, if any.

iii. Proposer must provide the names of all corporations, companies or other business entities controlled or affiliated with the Proposer, with a description of its type of business and the nature and extent of the ownership, control, or affiliation.

5. Business License or Receipt for Business Tax: A copy of current California business license or receipt for business tax issued by the city or county in which the business is located

f) Conflict of Interest: Proposer must show capacity to provide and maintain independent reviewers:

number,…